Provider Demographics
NPI:1942202015
Name:JOHANSEN, OLAF B (MD)
Entity Type:Individual
Prefix:DR
First Name:OLAF
Middle Name:B
Last Name:JOHANSEN
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 1:1215 HADLEY RD
Mailing Address - Street 2:STE 201
Mailing Address - City:MOORESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46158-2905
Mailing Address - Country:US
Mailing Address - Phone:317-834-2020
Mailing Address - Fax:317-831-9292
Practice Address - Street 1:1215 HADLEY RD
Practice Address - Street 2:STE 201
Practice Address - City:MOORESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46158-2905
Practice Address - Country:US
Practice Address - Phone:317-834-2020
Practice Address - Fax:317-831-9292
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040001A174400000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200008930AMedicaid
IN000000091932OtherANTHEM
INA14224Medicare UPIN