Provider Demographics
NPI:1154380053
Name:OLSEN, JOHN CLIFFORD (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CLIFFORD
Last Name:OLSEN
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 1:1055 BEVERLY PL
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-4002
Mailing Address - Country:US
Mailing Address - Phone:847-234-3058
Mailing Address - Fax:
Practice Address - Street 1:3001 6TH ST
Practice Address - Street 2:5TH DECK - HO&A
Practice Address - City:GREAT LAKES
Practice Address - State:IL
Practice Address - Zip Code:60088-2833
Practice Address - Country:US
Practice Address - Phone:847-688-5328
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology