Provider Demographics
NPI:1083672356
Name:OLSON, DAVID HENRY (DPM)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:HENRY
Last Name:OLSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 STATE STREET
Mailing Address - Street 2:
Mailing Address - City:LAPORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-3115
Mailing Address - Country:US
Mailing Address - Phone:219-362-5417
Mailing Address - Fax:219-325-3431
Practice Address - Street 1:1501 STATE ST
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-3115
Practice Address - Country:US
Practice Address - Phone:219-362-5417
Practice Address - Fax:219-325-3431
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000328A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN727460Medicare ID - Type UnspecifiedMEDICARE NUMBER
INT35008Medicare UPIN
IN100220320AMedicaid