Provider Demographics
NPI:1568433654
Name:OLIN, JOHN A (DPM)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:OLIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 WEST MAIN STREET
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:BOONTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07005-1165
Mailing Address - Country:US
Mailing Address - Phone:973-402-1973
Mailing Address - Fax:973-402-1969
Practice Address - Street 1:223 WEST MAIN STREET
Practice Address - Street 2:SUITE 1B
Practice Address - City:BOONTON
Practice Address - State:NJ
Practice Address - Zip Code:07005-1165
Practice Address - Country:US
Practice Address - Phone:973-402-1973
Practice Address - Fax:973-402-1969
Is Sole Proprietor?:No
Enumeration Date:2006-01-28
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00197700213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1879502Medicaid
NJ652879Medicare ID - Type Unspecified
652879Medicare UPIN
NJ1879502Medicaid