Provider Demographics
NPI:1891112819
Name:OLSON-BASORA, DANIELLE MARIE (MD)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:MARIE
Last Name:OLSON-BASORA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-6990
Mailing Address - Fax:239-343-4247
Practice Address - Street 1:2495 PALM RIDGE RD
Practice Address - Street 2:
Practice Address - City:SANIBEL
Practice Address - State:FL
Practice Address - Zip Code:33957-3201
Practice Address - Country:US
Practice Address - Phone:239-343-6990
Practice Address - Fax:239-343-4247
Is Sole Proprietor?:No
Enumeration Date:2014-03-27
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301113524207Q00000X
FLME164568207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL119434800Medicaid