Provider Demographics
NPI:1457444093
Name:OLSON, LANCE (OD)
Entity Type:Individual
Prefix:DR
First Name:LANCE
Middle Name:
Last Name:OLSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6801 MELTON RD STE C
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46403-3006
Mailing Address - Country:US
Mailing Address - Phone:219-730-4559
Mailing Address - Fax:219-938-3385
Practice Address - Street 1:6097 US HIGHWAY 6
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-5215
Practice Address - Country:US
Practice Address - Phone:219-763-1538
Practice Address - Fax:219-938-3385
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003103152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200400920Medicaid
IN199180Medicare ID - Type Unspecified
IN200400920Medicaid