Provider Demographics
NPI:1386775070
Name:OLSON, JARED CRAIG (OD)
Entity type:Individual
Prefix:DR
First Name:JARED
Middle Name:CRAIG
Last Name:OLSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1711 E 20TH ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-4309
Mailing Address - Country:US
Mailing Address - Phone:505-326-4080
Mailing Address - Fax:505-326-4260
Practice Address - Street 1:1711 E 20TH ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-4309
Practice Address - Country:US
Practice Address - Phone:505-326-4080
Practice Address - Fax:505-326-4260
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM569 NM152W00000X
CAOPT 12848152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM34759077Medicaid