Provider Demographics
NPI:1043301849
Name:OLSEN, JERRY GEORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:GEORGE
Last Name:OLSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JERRY
Other - Middle Name:
Other - Last Name:OLSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:33 LYNN BATTS
Mailing Address - Street 2:APARTMENT # 3203
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78218-3000
Mailing Address - Country:US
Mailing Address - Phone:210-820-3225
Mailing Address - Fax:210-567-8414
Practice Address - Street 1:6711 S NEW BRAUNFELS AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78223-3005
Practice Address - Country:US
Practice Address - Phone:210-531-7716
Practice Address - Fax:210-531-7478
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ51122084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG13027Medicare UPIN
TX8D8141Medicare ID - Type Unspecified