Provider Demographics
NPI:1154365369
Name:OLSON, BRADLEY GARRETT (MD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:GARRETT
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 1:2800 N VANCOUVER AVE
Mailing Address - Street 2:STE 165
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1630
Mailing Address - Country:US
Mailing Address - Phone:503-413-2902
Mailing Address - Fax:503-413-5220
Practice Address - Street 1:2800 N VANCOUVER AVE
Practice Address - Street 2:STE 165
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1630
Practice Address - Country:US
Practice Address - Phone:503-413-2902
Practice Address - Fax:503-413-5220
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2016-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD177926208000000X
NY206363208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01757060Medicaid
NYJ400074252Medicare PIN
NY01757060Medicaid
NYJ400010291Medicare PIN