Individual
MARK OLTERMANN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1500 S MAIN ST, FORT WORTH, TX 76104
(817) 921-3431
Mailing address
1617 HEMPHILL ST, ATTN CREDENTIALING, FORT WORTH, TX 76104-4709
(817) 702-3381
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
G8323
TX
207RC0200X
Critical Care Medicine (Internal Medicine) Physician
16376
NV
207RC0200X
Critical Care Medicine (Internal Medicine) Physician
Primary
G8323
TX
207RP1001X
Pulmonary Disease Physician
MED-PHYS-LIC-76336
MT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
150942401
—
TX
05
—
200003780A
—
OK
05
—
59339837
—
NM
Enumeration date
07/07/2006
Last updated
06/15/2021
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