Basic Information
| Provider Information | |||||||||
| NPI: | 1518067347 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OLSEN | ||||||||
| FirstName: | MAYNARD | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 N 500 W | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012252926 | ||||||||
| FaxNumber: | 8012292420 | ||||||||
| Practice Location | |||||||||
| Address1: | 575 S STATE ST | ||||||||
| Address2: | |||||||||
| City: | OREM | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840586303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012252926 | ||||||||
| FaxNumber: | 8012292420 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 09/30/2014 | ||||||||
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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 | 173000000X | 332060-1205 | UT | N | Other Service Providers | Legal Medicine | 207Q00000X | 332060-1205 | UT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.