Healthcare Provider Details

I. General information

NPI: 1740370766
Provider Name (Legal Business Name): JOHN ANTHON OLSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 CENTURY PARK EAST SUITE 610
LOS ANGELES CA
90067-2009
US

IV. Provider business mailing address

2080 CENTURY PARK EAST SUITE 610
LOS ANGELES CA
90067-2009
US

V. Phone/Fax

Practice location:
  • Phone: 310-552-9444
  • Fax: 310-552-1222
Mailing address:
  • Phone: 310-552-9444
  • Fax: 310-552-1222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberC34364
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: