Provider Demographics
NPI:1518095728
Name:OLSEN, ROBERT O JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:O
Last Name:OLSEN
Suffix:JR
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:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:5251 NE GLISAN ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-3052
Practice Address - Country:US
Practice Address - Phone:503-215-4860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD28601207R00000X, 2084P0800X
CODR.00688472084P0800X
NM2004-02702084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMQMYPR00689OtherMOLINA
NM201047052OtherPRES HEALTH PLAN
NM975076OtherPRO-NET AETNA
NMP00265595OtherPHCS
OR500628018Medicaid
NM57936757Medicaid
NM85-0105601OtherADMAR, BEECH ST AND OTHER
OR270948Medicaid
OR270948Medicaid
NMI21719Medicare UPIN
NM343433600Medicare ID - Type Unspecified