Provider Demographics
NPI:1598746679
Name:OLSON, KENNETH R (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
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 1:105 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WAUKON
Mailing Address - State:IA
Mailing Address - Zip Code:52172-1735
Mailing Address - Country:US
Mailing Address - Phone:563-568-3449
Mailing Address - Fax:563-568-4947
Practice Address - Street 1:105 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WAUKON
Practice Address - State:IA
Practice Address - Zip Code:52172-1735
Practice Address - Country:US
Practice Address - Phone:563-568-3449
Practice Address - Fax:563-568-4947
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA19201207Q00000X
WI40911207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D75879Medicare UPIN