Healthcare Provider Details

I. General information

NPI: 1346229788
Provider Name (Legal Business Name): RUSSELL J. OLSON M. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3259 CATLIN AVE
QUANTICO VA
22134-5109
US

IV. Provider business mailing address

4501 GILBERTSON RD
FAIRFAX VA
22032-3615
US

V. Phone/Fax

Practice location:
  • Phone: 703-432-0329
  • Fax:
Mailing address:
  • Phone: 703-503-0348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number27710
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: