Provider Demographics
NPI:1306812045
Name:OLSON, ELLEN L (MD)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:L
Last Name:OLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:436 SUNRISE DR
Mailing Address - Street 2:
Mailing Address - City:SPRING GREEN
Mailing Address - State:WI
Mailing Address - Zip Code:53588-9286
Mailing Address - Country:US
Mailing Address - Phone:608-588-2502
Mailing Address - Fax:
Practice Address - Street 1:436 SUNRISE DR
Practice Address - Street 2:
Practice Address - City:SPRING GREEN
Practice Address - State:WI
Practice Address - Zip Code:53588-9286
Practice Address - Country:US
Practice Address - Phone:608-588-2502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38198207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32307100Medicaid
WI080129928OtherRAILROAD MEDICARE