Provider Demographics
NPI:1235142274
Name:OLSEN, THOMAS J (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:OLSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3691 RUTGER ST
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2515
Mailing Address - Country:US
Mailing Address - Phone:314-977-4440
Mailing Address - Fax:
Practice Address - Street 1:3660 VISTA AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-2540
Practice Address - Country:US
Practice Address - Phone:314-977-6100
Practice Address - Fax:314-977-6137
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR2C73207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine