Provider Demographics
NPI:1124057047
Name:OLOFSSON, DONALD ERICK (DO)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:ERICK
Last Name:OLOFSSON
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 1:60 TYGERT LN
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-8258
Mailing Address - Country:US
Mailing Address - Phone:815-758-2232
Mailing Address - Fax:
Practice Address - Street 1:2475 BETHANY RD
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3116
Practice Address - Country:US
Practice Address - Phone:815-748-3674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6832085R0202X
CA2OA 67862085R0202X
IN02001516A2085R0202X
FLOS 99652085R0202X
IL2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILKO3267Medicare UPIN