Provider Demographics
NPI:1639279243
Name:OLSON, DONALD M (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:M
Last Name:OLSON
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:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:541-732-8400
Mailing Address - Fax:541-732-8401
Practice Address - Street 1:920 ROYAL AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6169
Practice Address - Country:US
Practice Address - Phone:541-732-8400
Practice Address - Fax:541-732-8401
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD1699212084N0402X
CAG487252084N0600X, 2084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500625496Medicaid
OR500625496Medicaid
CA00G487253Medicare PIN
CA00G487250Medicaid