Provider Demographics
NPI:1568565505
Name:OLSON, EDMUND (MD)
Entity Type:Individual
Prefix:
First Name:EDMUND
Middle Name:
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 1:100 RETREAT AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106
Mailing Address - Country:US
Mailing Address - Phone:860-246-8568
Mailing Address - Fax:860-728-5076
Practice Address - Street 1:100 RETREAT AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106
Practice Address - Country:US
Practice Address - Phone:860-246-8568
Practice Address - Fax:860-728-5076
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT018733207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C64790Medicare UPIN