Provider Demographics
NPI:1417041591
Name:OLSON, THEODORE (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:OLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 UNIVERSITY AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:E PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94303-2212
Mailing Address - Country:US
Mailing Address - Phone:650-494-1000
Mailing Address - Fax:650-322-8228
Practice Address - Street 1:196 SOTOYOME ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4800
Practice Address - Country:US
Practice Address - Phone:707-528-0565
Practice Address - Fax:707-528-6403
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA212232174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist