Provider Demographics
NPI:1740254226
Name:OLSON, ANGIE EVELYN
Entity type:Individual
Prefix:MRS
First Name:ANGIE
Middle Name:EVELYN
Last Name:OLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:ANGIE
Other - Middle Name:EVELYN
Other - Last Name:OLSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:1706 AUTUMN HILL DR
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:WI
Mailing Address - Zip Code:53593-7913
Mailing Address - Country:US
Mailing Address - Phone:608-845-6225
Mailing Address - Fax:
Practice Address - Street 1:462 COMMERCE DR STE A
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-4987
Practice Address - Country:US
Practice Address - Phone:608-833-0062
Practice Address - Fax:608-833-0431
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIWI 2773152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39176498400OtherUNITY
WI38611800Medicaid
WIU77239Medicare ID - Type Unspecified