Basic Information
Provider Information | |||||||||
NPI: | 1932157138 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | OLSEN | ||||||||
FirstName: | RICHARD | ||||||||
MiddleName: | K | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1055 N 500 W | ||||||||
Address2: | ATTN: CREDENTIALING | ||||||||
City: | PROVO | ||||||||
State: | UT | ||||||||
PostalCode: | 846043305 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8013548225 | ||||||||
FaxNumber: | 8014180941 | ||||||||
Practice Location | |||||||||
Address1: | 1055 N 500 W | ||||||||
Address2: | SUITE 212 | ||||||||
City: | PROVO | ||||||||
State: | UT | ||||||||
PostalCode: | 846043305 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8013742362 | ||||||||
FaxNumber: | 8014298196 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/04/2006 | ||||||||
LastUpdateDate: | 03/17/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/17/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2743161205 | UT | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 110116385 | 01 | UT | PALMETTO GBA | OTHER | 107008142101 | 01 | UT | IHC HEALTHPLANS | OTHER | 220734 | 01 | UT | DMBA | OTHER | 35882 | 01 | UT | PEHP | OTHER | QMAF03080 | 01 | UT | ALTIUS | OTHER |