Provider Demographics
NPI:1194728790
Name:OLSON, RICHARD A (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
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:PO BOX 657
Mailing Address - Street 2:
Mailing Address - City:DEMOREST
Mailing Address - State:GA
Mailing Address - Zip Code:30535-0657
Mailing Address - Country:US
Mailing Address - Phone:706-754-8339
Mailing Address - Fax:706-754-8460
Practice Address - Street 1:855 AUSTIN DR
Practice Address - Street 2:
Practice Address - City:DEMOREST
Practice Address - State:GA
Practice Address - Zip Code:30535-4513
Practice Address - Country:US
Practice Address - Phone:706-754-8339
Practice Address - Fax:706-754-8460
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029924208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000355044HMedicaid
GA000355044HMedicaid
GAD42426Medicare UPIN