1225020472 NPI number — BRUCE A OLSON DPM

Table of content: BRUCE A OLSON DPM (NPI 1225020472)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225020472 NPI number — BRUCE A OLSON DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OLSON
Provider First Name:
BRUCE
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225020472
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/05/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2035 SAVIERS RD
Provider Second Line Business Mailing Address:
STE 5
Provider Business Mailing Address City Name:
OXNARD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93033-3650
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-486-8710
Provider Business Mailing Address Fax Number:
805-486-2856

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2035 SAVIERS RD
Provider Second Line Business Practice Location Address:
STE 5
Provider Business Practice Location Address City Name:
OXNARD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93033-3650
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-486-8710
Provider Business Practice Location Address Fax Number:
805-486-2856
Provider Enumeration Date:
08/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  E1206 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0883610001 . This is a "CIGNA MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 000E120607 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00194968 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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