Provider Demographics
NPI:1952374795
Name:OLSON, JEFFREY A (MD,)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
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 1:2740 W FOSTER AVE
Mailing Address - Street 2:LL7
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625
Mailing Address - Country:US
Mailing Address - Phone:773-878-8200
Mailing Address - Fax:773-293-4197
Practice Address - Street 1:5215 N CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-7014
Practice Address - Country:US
Practice Address - Phone:773-878-3627
Practice Address - Fax:773-275-5860
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA75543207R00000X
IL0000207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036.110640OtherSTATE LICENSE
IL336.071295OtherCDS LIC
ILBO7729025OtherDEA LIC
ILH67602Medicare UPIN
ILF400275534Medicare PIN