Provider Demographics
NPI:1518067347
Name:OLSEN, MAYNARD ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:MAYNARD
Middle Name:ROBERT
Last Name:OLSEN
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 1:1055 N 500 W
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-225-2926
Mailing Address - Fax:801-229-2420
Practice Address - Street 1:575 S STATE ST
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-6303
Practice Address - Country:US
Practice Address - Phone:801-225-2926
Practice Address - Fax:801-229-2420
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT332060-1205173000000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No173000000XOther Service ProvidersLegal Medicine