Provider Demographics
NPI:1720003866
Name:OLSON, LARRY (OD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:
Last Name:OLSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 W 13 MILE RD
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-1844
Mailing Address - Country:US
Mailing Address - Phone:248-577-3659
Mailing Address - Fax:248-588-9320
Practice Address - Street 1:735 JOHN R RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-5856
Practice Address - Country:US
Practice Address - Phone:248-544-3290
Practice Address - Fax:248-528-4040
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002867152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU35130Medicare UPIN