Provider Demographics
NPI:1639121015
Name:OLSEN, ERIK W (MD)
Entity Type:Individual
Prefix:
First Name:ERIK
Middle Name:W
Last Name:OLSEN
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 1:2140 GRAND AVE STE 125
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-6802
Mailing Address - Country:US
Mailing Address - Phone:909-630-7875
Mailing Address - Fax:909-469-2107
Practice Address - Street 1:2140 GRAND AVE STE 125
Practice Address - Street 2:
Practice Address - City:CHINO HILLS
Practice Address - State:CA
Practice Address - Zip Code:91709-6802
Practice Address - Country:US
Practice Address - Phone:909-630-7875
Practice Address - Fax:909-469-2107
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA94078207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1639121015Medicaid
CABO9645992OtherFEDERAL DEA