Basic Information
| Provider Information | |||||||||
| NPI: | 1558359349 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OLMSTED | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | B. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2215 LANDOVER PL | ||||||||
| Address2: | |||||||||
| City: | LYNCHBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245012115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349473944 | ||||||||
| FaxNumber: | 8666178273 | ||||||||
| Practice Location | |||||||||
| Address1: | 2215 LANDOVER PL | ||||||||
| Address2: | |||||||||
| City: | LYNCHBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245012115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349473944 | ||||||||
| FaxNumber: | 8666178273 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2005 | ||||||||
| LastUpdateDate: | 03/14/2014 | ||||||||
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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 | 174400000X | 0101102725 | VA | N | Other Service Providers | Specialist | 207Q00000X | 0101102725 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 005620376 | 05 | VA | MEDICAID | 1558359349 | 05 | VA | MEDICAID |