Healthcare Provider Details

I. General information

NPI: 1023005261
Provider Name (Legal Business Name): THOMAS GEORGE OLSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 01/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7835 PARAGON RD
DAYTON OH
45459-4021
US

IV. Provider business mailing address

7835 PARAGON RD
DAYTON OH
45459-4021
US

V. Phone/Fax

Practice location:
  • Phone: 937-434-2351
  • Fax: 937-434-1381
Mailing address:
  • Phone: 937-434-2351
  • Fax: 937-434-1381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number350460580
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number350460580
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: