Provider Demographics
NPI:1053546762
Name:MID DAKOTA PODIATRY
Entity type:Organization
Organization Name:MID DAKOTA PODIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:D
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:605-222-0661
Mailing Address - Street 1:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:PIERRE
Mailing Address - State:SD
Mailing Address - Zip Code:57501-0309
Mailing Address - Country:US
Mailing Address - Phone:605-222-0661
Mailing Address - Fax:
Practice Address - Street 1:608 E GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:GETTYSBURG
Practice Address - State:SD
Practice Address - Zip Code:57442-1325
Practice Address - Country:US
Practice Address - Phone:605-222-0661
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-26
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD164213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
6466Medicare PIN