Provider Demographics
NPI:1174507834
Name:OLSON, JEFFREY CHARLES (DO)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:CHARLES
Last Name:OLSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10731 HALFMOON SHOAL RD APT 103
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-1753
Mailing Address - Country:US
Mailing Address - Phone:800-224-0859
Mailing Address - Fax:
Practice Address - Street 1:10731 HALFMOON SHOAL RD APT 103
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-1753
Practice Address - Country:US
Practice Address - Phone:800-224-0859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7357207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL57464OtherBCBS
FL251761200Medicaid
FL57464OtherBCBS
FL57464WMedicare ID - Type Unspecified