Provider Demographics
NPI:1740229400
Name:OLSON, THOMAS JOHN (OD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:JOHN
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:PO BOX 318
Mailing Address - Street 2:
Mailing Address - City:OCONTO
Mailing Address - State:WI
Mailing Address - Zip Code:54153-0318
Mailing Address - Country:US
Mailing Address - Phone:920-834-2733
Mailing Address - Fax:920-834-4955
Practice Address - Street 1:1028 MAIN ST
Practice Address - Street 2:
Practice Address - City:OCONTO
Practice Address - State:WI
Practice Address - Zip Code:54153-1538
Practice Address - Country:US
Practice Address - Phone:920-834-2733
Practice Address - Fax:920-834-4955
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1597-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38508500Medicaid
WI6747730001Medicare NSC
WIT62921Medicare UPIN
000087375Medicare PIN