Provider Demographics
NPI:1396700761
Name:OLSEN, DANIEL J (DO)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:J
Last Name:OLSEN
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 1:2000 BURTON ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-4670
Mailing Address - Country:US
Mailing Address - Phone:616-241-5534
Mailing Address - Fax:616-241-4868
Practice Address - Street 1:2000 BURTON ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-4670
Practice Address - Country:US
Practice Address - Phone:616-241-5534
Practice Address - Fax:616-241-4868
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDO0099212086S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2880701Medicaid
MI6728140001Medicare PIN
MIF40899Medicare UPIN
MI2880701Medicaid