MEDICARE: JESSE D. OLSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist	164	SD

General Provider Information

NPI Number	:	1124286760
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JESSE D. OLSON

Provider Business Mailing Address
First Line	:	PO BOX 309
Second Line	:
City	:	PIERRE
State	:	SD
Zip	:	57501-0309
Country	:	US
Telephone Number	:	605-222-0661
Fax Number	:

Provider Business Practice Location Address
First Line	:	202 ISLAND DR
Second Line	:	SUITE 1
City	:	FORT PIERRE
State	:	SD
Zip	:	57532-7302
Country	:	US
Telephone Number	:	605-222-0661
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JESSE D OLSON
Credential	:	DPM
Telephone Number	:	605-222-0661

Provider Enumeration Date	:	05/30/2008
Last Update Date	:	06/23/2009

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