Provider Demographics
NPI:1437851995
Name:OLSEN, COREY DAVID
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:DAVID
Last Name:OLSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2028 FAIRMOUNT AVE APT 2R
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-2609
Mailing Address - Country:US
Mailing Address - Phone:302-690-2570
Mailing Address - Fax:
Practice Address - Street 1:2028 FAIRMOUNT AVE APT 2R
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19130-2609
Practice Address - Country:US
Practice Address - Phone:302-690-2570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program