Provider Demographics
NPI:1265489306
Name:OLSSON, LEIF ERIC (MD)
Entity Type:Individual
Prefix:
First Name:LEIF
Middle Name:ERIC
Last Name:OLSSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:L.
Other - Middle Name:ERIC
Other - Last Name:OLSSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1524 ATWOOD AVE
Mailing Address - Street 2:SUITE 322
Mailing Address - City:JOHNSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02919-3228
Mailing Address - Country:US
Mailing Address - Phone:401-331-7400
Mailing Address - Fax:401-331-7410
Practice Address - Street 1:1524 ATWOOD AVE
Practice Address - Street 2:SUITE 322
Practice Address - City:JOHNSTON
Practice Address - State:RI
Practice Address - Zip Code:02919-3228
Practice Address - Country:US
Practice Address - Phone:401-331-7400
Practice Address - Fax:401-331-7410
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD11442174400000X
MEMD24019208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7056699Medicaid
RI7056699Medicaid