Provider Demographics
NPI:1295789659
Name:OLSEN, ROGER (MD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:OLSEN
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 1:840 N 5TH AVE
Mailing Address - Street 2:STE 2100
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-3045
Mailing Address - Country:US
Mailing Address - Phone:360-582-2850
Mailing Address - Fax:360-582-2851
Practice Address - Street 1:840 N 5TH AVE
Practice Address - Street 2:STE 2100
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382-3045
Practice Address - Country:US
Practice Address - Phone:360-582-2850
Practice Address - Fax:360-582-2851
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00019693207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8319204Medicaid
WA0158210OtherLABOR & INDUSTRIES
WA8319204Medicaid
WAA07997Medicare UPIN
WA8319204Medicaid