Provider Demographics
NPI:1932169604
Name:OLSON, JOHN C (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
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 1:560 W 800 N
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-3746
Mailing Address - Country:US
Mailing Address - Phone:801-225-6246
Mailing Address - Fax:801-225-1525
Practice Address - Street 1:2910 WASHINGTON BLVD
Practice Address - Street 2:#310
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-3751
Practice Address - Country:US
Practice Address - Phone:801-621-6671
Practice Address - Fax:801-627-6679
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-25
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT17027812052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT841410485002Medicaid
UT006961001Medicare ID - Type Unspecified
UT841410485002Medicaid