Basic Information
| Provider Information | |||||||||
| NPI: | 1982737417 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OLSON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3341 SLY PARK RD | ||||||||
| Address2: | |||||||||
| City: | POLLOCK PINES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 957269519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306447021 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 838 BEACH COURT | ||||||||
| Address2: | |||||||||
| City: | COLOMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306267252 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 03-991219 | CA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 03-991219 | 01 | CA | CASII | OTHER |