Provider Demographics
NPI:1629077722
Name:OLSON, KEVIN F II (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:F
Last Name:OLSON
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:48 ROUTE 25A
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-1431
Mailing Address - Country:US
Mailing Address - Phone:631-862-3696
Mailing Address - Fax:631-862-3698
Practice Address - Street 1:48 ROUTE 25A
Practice Address - Street 2:SUITE 210
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-1431
Practice Address - Country:US
Practice Address - Phone:631-862-3696
Practice Address - Fax:631-862-3698
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2010-07-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY139236207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00970347Medicaid
NY20A521Medicare ID - Type Unspecified
NY00970347Medicaid