Basic Information
| Provider Information | |||||||||
| NPI: | 1649357138 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OLSON | ||||||||
| FirstName: | JAMES | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1213 15TH AVE W | ||||||||
| Address2: | |||||||||
| City: | WILLISTON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 588013800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7015727641 | ||||||||
| FaxNumber: | 7015727710 | ||||||||
| Practice Location | |||||||||
| Address1: | 1213 15TH AVE W | ||||||||
| Address2: | |||||||||
| City: | WILLISTON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 588013800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7015727641 | ||||||||
| FaxNumber: | 7015727710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 5995 | ND | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 16478 | 05 | ND | MEDICAID |