Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204C00000X | Sports Medicine Doctor | G69571 | CA |
Y | 207R00000X | Internist | G69571 | CA |
Y | 111NI0900X | Internist | G69571 | CA |
NPI | 1376537399 |
---|---|
Provider Name | Dr. Jeffrey D. Olsen |
First Address | Irvine, CA 92612-2729 |
Second Address | Irvine, CA 92612 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/09/2005 |
Last Update Date | 26/06/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
F76805 | (02) | CA |