Healthcare Provider Details

I. General information

NPI: 1124057047
Provider Name (Legal Business Name): DONALD ERICK OLOFSSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2475 BETHANY RD
SYCAMORE IL
60178-3116
US

IV. Provider business mailing address

60 TYGERT LN
DEKALB IL
60115-8258
US

V. Phone/Fax

Practice location:
  • Phone: 815-748-3674
  • Fax:
Mailing address:
  • Phone: 815-758-2232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number683
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2OA 6786
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number02001516A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberOS 9965
License Number StateFL
# 5
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: