Basic Information
Provider Information
NPI: 1770144701
EntityType: 2
ReplacementNPI:  
OrganizationName: OLSV3 PLLC
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Mailing Information
Address1: 3414 GOLDEN RD
Address2:  
City: TYLER
State: TX
PostalCode: 757018336
CountryCode: US
TelephoneNumber: 7137992300
FaxNumber:  
Practice Location
Address1: 3414 GOLDEN RD
Address2:  
City: TYLER
State: TX
PostalCode: 757018336
CountryCode: US
TelephoneNumber: 7137992300
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/20/2019
LastUpdateDate: 06/20/2019
NPIDeactivationReasonCode:  
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AuthorizedOfficialLastName: WILIAMSON
AuthorizedOfficialFirstName: JACK
AuthorizedOfficialMiddleName: BRYAN
AuthorizedOfficialTitleorPosition: PRINCIPLE PHYSICIAN
AuthorizedOfficialTelephone: 7137992300
IsSoleProprietor:  
IsOrganizationSubpart: N
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AuthorizedOfficialCredential: MD
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207X00000X  Y193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansOrthopaedic Surgery 

No ID Information.


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