Provider Demographics
NPI:1659454536
Name:OLSON, GARY (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:OLSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 COMMACK RD
Mailing Address - Street 2:SUITE 10
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-3403
Mailing Address - Country:US
Mailing Address - Phone:631-462-0917
Mailing Address - Fax:631-462-1038
Practice Address - Street 1:285 COMMACK RD
Practice Address - Street 2:SUITE 10
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-3403
Practice Address - Country:US
Practice Address - Phone:631-462-0917
Practice Address - Fax:631-462-1038
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYXO9393-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5897489OtherGHI
NYX7S551OtherEMPIRE BLUE CROSS BLUE SH
NYU75587Medicare UPIN
NYX7S551OtherEMPIRE BLUE CROSS BLUE SH