Provider Demographics
NPI:1598883795
Name:OLSEN, DOUGLAS M (OD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:M
Last Name:OLSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:12350 W DRIFTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-0025
Mailing Address - Country:US
Mailing Address - Phone:208-323-9519
Mailing Address - Fax:
Practice Address - Street 1:300 N MILWAUKEE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9121
Practice Address - Country:US
Practice Address - Phone:208-323-9519
Practice Address - Fax:208-376-0050
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP 904152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist