Healthcare Provider Details

I. General information

NPI: 1952374795
Provider Name (Legal Business Name): JEFFREY A. OLSON M.D,
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 03/07/2023
Certification Date: 10/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5215 N CALIFORNIA AVE
CHICAGO IL
60625-7014
US

IV. Provider business mailing address

2740 W FOSTER AVE LL7
CHICAGO IL
60625
US

V. Phone/Fax

Practice location:
  • Phone: 773-878-3627
  • Fax: 773-275-5860
Mailing address:
  • Phone: 773-878-8200
  • Fax: 773-293-4197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA75543
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0000
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: