Provider Demographics
NPI:1376537399
Name:OLSEN, JEFFREY D (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:D
Last Name:OLSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:18124 CULVER DR
Mailing Address - Street 2:SUITE F
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-2729
Mailing Address - Country:US
Mailing Address - Phone:949-552-9393
Mailing Address - Fax:949-552-5872
Practice Address - Street 1:18124 CULVER DR
Practice Address - Street 2:SUITE F
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612
Practice Address - Country:US
Practice Address - Phone:949-552-9393
Practice Address - Fax:949-552-5872
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-06
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG69571204C00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF76805Medicare UPIN