Provider Demographics
NPI:1407859184
Name:OLSON, KEVIN DONALD (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:DONALD
Last Name:OLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:19260 SW 65TH AVE
Mailing Address - Street 2:STE 435
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-7707
Mailing Address - Country:US
Mailing Address - Phone:503-692-2032
Mailing Address - Fax:503-692-4450
Practice Address - Street 1:19260 SW 65TH AVE
Practice Address - Street 2:STE 435
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-7707
Practice Address - Country:US
Practice Address - Phone:503-692-2032
Practice Address - Fax:503-692-4450
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD17386207RH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2006586Medicaid
OR072780Medicaid
WAGAB33010Medicare PIN
OR072780Medicaid
ORE47563Medicare UPIN