Provider Demographics
NPI:1639178882
Name:OLSEN, RUSSELL G (DPM)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:G
Last Name:OLSEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1811 W ROYAL HUNTE DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84720-8273
Mailing Address - Country:US
Mailing Address - Phone:435-586-2225
Mailing Address - Fax:435-867-1909
Practice Address - Street 1:1811 W ROYAL HUNTE DR
Practice Address - Street 2:SUITE 2
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84720-8273
Practice Address - Country:US
Practice Address - Phone:435-586-2225
Practice Address - Fax:435-867-1909
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT106765-0501213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870545030OL1OtherEDUCATORS MUTUAL
UT870545030006OtherMEDICAID DME
UT1069500001OtherRR MEDICARE DME
UT528688204001OtherBLUECROSS PPO
UT73654OtherINTERMOUNTAIN HEALTH CARE
UT167286OtherDMBA
UT528688204001OtherBLUECROSS PPO
UT1069500001Medicare NSC