Basic Information
| Provider Information | |||||||||
| NPI: | 1831466648 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OLSON | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11109 PARKVIEW PLAZA DR # 117 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451701 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11108 PARKVIEW CIRCLE DR | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602665700 | ||||||||
| FaxNumber: | 2602665920 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2011 | ||||||||
| LastUpdateDate: | 10/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 34011212 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 390200000X | TN505962 | OH | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RC0000X | 02005067A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | FO5071991 | 01 | IN | DEA NUMBER | OTHER | AG2820579-G2855 | 01 | OH | DEA NUMBER | OTHER |