Basic Information
| Provider Information | |||||||||
| NPI: | 1194710632 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OLSSON | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9007 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229069007 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1204 W MAIN ST FL 6 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229084300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349245321 | ||||||||
| FaxNumber: | 4349245352 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2005 | ||||||||
| LastUpdateDate: | 11/09/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 0101263142 | VA | Y | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 9801733 | NC | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1163A | 01 | NC | BCBS NC | OTHER | 1194710632 | 05 | NC | MEDICAID | 2262361B | 01 | NC | MEDICARE | OTHER | 990014475 | 01 | NC | RAILROAD MEDICARE | OTHER |