Provider Demographics
NPI:1720264203
Name:OLSON, ROBERT L
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:L
Last Name:OLSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 PLANK AVENUE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PAOLI
Mailing Address - State:PA
Mailing Address - Zip Code:19301
Mailing Address - Country:US
Mailing Address - Phone:610-644-8222
Mailing Address - Fax:
Practice Address - Street 1:21 PLANK AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:PAOLI
Practice Address - State:PA
Practice Address - Zip Code:19301-1785
Practice Address - Country:US
Practice Address - Phone:610-644-8222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-15
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0249440001Medicare NSC