Healthcare Provider Details

I. General information

NPI: 1932180361
Provider Name (Legal Business Name): JOHN R OLSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/11/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3851 ROGER BROOKE DR MCHE-QD (CREDENTIALS)
FORT SAM HOUSTON TX
78234-4501
US

IV. Provider business mailing address

639 ELIZABETH RD
SAN ANTONIO TX
78209-6134
US

V. Phone/Fax

Practice location:
  • Phone: 210-916-4143
  • Fax:
Mailing address:
  • Phone: 210-828-2021
  • Fax: 210-828-2021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberMD041023E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: