Provider Demographics
NPI:1942281027
Name:OLSEN, LARRY TODD (DO)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:TODD
Last Name:OLSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:LARRY
Other - Middle Name:TODD
Other - Last Name:OLSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:3400 S DOUGLAS BLVD
Mailing Address - Street 2:302
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73150
Mailing Address - Country:US
Mailing Address - Phone:405-733-8000
Mailing Address - Fax:405-733-7820
Practice Address - Street 1:3400 S DOUGLAS BLVD
Practice Address - Street 2:302
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73150
Practice Address - Country:US
Practice Address - Phone:405-733-8000
Practice Address - Fax:405-733-7820
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4132207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200035880AMedicaid
OK243428801Medicare ID - Type Unspecified
OK200035880AMedicaid