Provider Demographics
NPI:1487034682
Name:OLSEN, BRYCE DAVID (DO)
Entity Type:Individual
Prefix:
First Name:BRYCE
Middle Name:DAVID
Last Name:OLSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4531 E HAMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-3366
Mailing Address - Country:US
Mailing Address - Phone:208-360-3485
Mailing Address - Fax:
Practice Address - Street 1:1501 N CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85724-0001
Practice Address - Country:US
Practice Address - Phone:520-626-6053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-02
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR2501208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics