Healthcare Provider Details

I. General information

NPI: 1205889417
Provider Name (Legal Business Name): BENJY OLSEN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 10/04/2022
Certification Date: 10/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1027 WASHINGTON AVE
DETROIT LAKES MN
56501-3409
US

IV. Provider business mailing address

1702 UNIVERSITY DR S
FARGO ND
58103-4940
US

V. Phone/Fax

Practice location:
  • Phone: 188-475-6112
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number187
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number00764
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number770
License Number StateMN
# 4
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number770
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: