Provider Demographics
NPI:1962633230
Name:OLSON, KIM ERIC (MD)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:ERIC
Last Name:OLSON
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 1:530 W 148TH ST
Mailing Address - Street 2:2
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031-4108
Mailing Address - Country:US
Mailing Address - Phone:646-285-7863
Mailing Address - Fax:212-951-3389
Practice Address - Street 1:530 W 148TH ST
Practice Address - Street 2:2
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031-4108
Practice Address - Country:US
Practice Address - Phone:646-285-7863
Practice Address - Fax:212-951-3389
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-04
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203757207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG36382Medicare UPIN