Provider Demographics
NPI:1629150743
Name:OLSSON, ROGER B (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:B
Last Name:OLSSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:11601 HARBOUR POINTE BLVD.
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MUKILTEO
Mailing Address - State:WA
Mailing Address - Zip Code:98275-5566
Mailing Address - Country:US
Mailing Address - Phone:425-921-9489
Mailing Address - Fax:425-275-5863
Practice Address - Street 1:11601 HARBOUR POINTE B LVD
Practice Address - Street 2:SUITE 200
Practice Address - City:MUKILTEO
Practice Address - State:WA
Practice Address - Zip Code:98275-5566
Practice Address - Country:US
Practice Address - Phone:425-921-9489
Practice Address - Fax:425-275-5863
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WA00015303207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1690908Medicaid
WA1690908Medicaid
WAAB20771Medicare ID - Type Unspecified