Healthcare Provider Details

I. General information

NPI: 1194710632
Provider Name (Legal Business Name): JOHN M OLSSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 11/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1204 W MAIN ST FL 6
CHARLOTTESVILLE VA
22908-4300
US

IV. Provider business mailing address

PO BOX 9007
CHARLOTTESVILLE VA
22906-9007
US

V. Phone/Fax

Practice location:
  • Phone: 434-924-5321
  • Fax: 434-924-5352
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101263142
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number9801733
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: