Provider Demographics
NPI:1235237744
Name:OLSEN, GORDON S (DOPC)
Entity Type:Individual
Prefix:MR
First Name:GORDON
Middle Name:S
Last Name:OLSEN
Suffix:
Gender:M
Credentials:DOPC
Other - Prefix:
Other - First Name:GORDON
Other - Middle Name:S
Other - Last Name:OLSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DOPC
Mailing Address - Street 1:210 W 300 N
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:UT
Mailing Address - Zip Code:84066-2336
Mailing Address - Country:US
Mailing Address - Phone:435-725-7448
Mailing Address - Fax:435-722-9291
Practice Address - Street 1:210 W 300 N
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:UT
Practice Address - Zip Code:84066-2336
Practice Address - Country:US
Practice Address - Phone:435-722-4691
Practice Address - Fax:435-722-9291
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2689281204207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY117765600Medicaid
G53879Medicare UPIN
WY10415Medicare ID - Type Unspecified