Provider Demographics
NPI:1568563435
Name:OLSON, ERIC JON (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:JON
Last Name:OLSON
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 1:1211 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-3106
Mailing Address - Country:US
Mailing Address - Phone:203-755-0163
Mailing Address - Fax:203-753-3415
Practice Address - Street 1:1211 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-3106
Practice Address - Country:US
Practice Address - Phone:203-755-0163
Practice Address - Fax:203-753-3415
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT034638202C00000X, 207X00000X
CT064638207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No202C00000XAllopathic & Osteopathic PhysiciansIndependent Medical Examiner
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTNHS540OtherOXFORD
CT0R3416OtherHEALTHNET
CT010034638CT01OtherBLUE CROSS
CT034638OtherCONNECTICARE
CT2305230OtherUNITED HC
CT0R3416OtherHEALTHNET