Healthcare Provider Details

I. General information

NPI: 1932394186
Provider Name (Legal Business Name): BENJAMIN OLSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2007
Last Update Date: 07/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 SUNSET DR STE F
LA GRANDE OR
97850
US

IV. Provider business mailing address

PO BOX 3290
LA GRANDE OR
97850-7290
US

V. Phone/Fax

Practice location:
  • Phone: 541-663-3100
  • Fax: 541-975-5135
Mailing address:
  • Phone: 541-963-1967
  • Fax: 541-963-1837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberDO162272
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number58002398
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: