Provider Demographics
NPI:1366463226
Name:JAY E. OLSSON, D.O., P.A.
Entity Type:Organization
Organization Name:JAY E. OLSSON, D.O., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:OLSSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:321-242-9031
Mailing Address - Street 1:401 N WICKHAM RD
Mailing Address - Street 2:SUITE S
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-8659
Mailing Address - Country:US
Mailing Address - Phone:321-242-9031
Mailing Address - Fax:321-242-9035
Practice Address - Street 1:401 N WICKHAM RD
Practice Address - Street 2:SUITE S
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-8659
Practice Address - Country:US
Practice Address - Phone:321-242-9031
Practice Address - Fax:321-242-9035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS00040872081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK5335OtherMEDICARE ID