Provider Demographics
NPI:1083775084
Name:OLSON, TODD DONOVAN (OD)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:DONOVAN
Last Name:OLSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 BRYANT ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-1713
Mailing Address - Country:US
Mailing Address - Phone:320-219-0782
Mailing Address - Fax:
Practice Address - Street 1:2306 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-3459
Practice Address - Country:US
Practice Address - Phone:320-763-7782
Practice Address - Fax:320-763-0504
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2100152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN370025900Medicaid
MN410002191Medicare PIN
MNU10095Medicare UPIN