Provider Demographics
NPI:1790713543
Name:OLSON, KEITH J (DO)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:J
Last Name:OLSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 JEFFERSON RD
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55057-3081
Mailing Address - Country:US
Mailing Address - Phone:507-663-9000
Mailing Address - Fax:651-241-0775
Practice Address - Street 1:1400 JEFFERSON RD
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55057-3081
Practice Address - Country:US
Practice Address - Phone:507-663-9000
Practice Address - Fax:651-241-0775
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN29720207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA010050518OtherRAILROAD MEDICARE
MN378877600Medicaid
MN54035OLOtherBCBS
MNN003453OtherCHAMPUS
GA010050518OtherRAILROAD MEDICARE
MN5435OLMedicare PIN
MN089004009Medicare ID - Type Unspecified