Provider Demographics
NPI:1326072752
Name:OLSON, JAY R (OD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:R
Last Name:OLSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12511 WAYZATA BLVD
Mailing Address - Street 2:RIDGEDALE CENTER
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-1938
Mailing Address - Country:US
Mailing Address - Phone:952-591-1970
Mailing Address - Fax:952-591-1972
Practice Address - Street 1:12511 WAYZATA BLVD
Practice Address - Street 2:RIDGEDALE CENTER
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-1938
Practice Address - Country:US
Practice Address - Phone:952-591-1970
Practice Address - Fax:952-591-1972
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN2325152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN222141100Medicaid
MN222141100Medicaid
MN410000346Medicare ID - Type Unspecified