Basic Information
| Provider Information | |||||||||
| NPI: | 1609868801 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OLLO | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5255 E STOP 11 RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462376340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175284723 | ||||||||
| FaxNumber: | 3175284699 | ||||||||
| Practice Location | |||||||||
| Address1: | 5255 E STOP 11 RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462376340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175284723 | ||||||||
| FaxNumber: | 3175284699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 11/26/2018 | ||||||||
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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 | 207X00000X | 01039941 | IN | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207Q00000X | 01039941A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000093073 | 01 | IN | BLUE CROSS BLUE SHIELD | OTHER | 100118220A | 05 | IN | MEDICAID |