Provider Demographics
NPI:1720051485
Name:OLSEN, WALTER L (MD)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:L
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:PO BOX 232410
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193-2410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 W ARBOR DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-9000
Practice Address - Country:US
Practice Address - Phone:800-926-8273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG550912085N0700X, 2085R0202X, 2085B0100X, 2085U0001X, 2085N0904X, 208VP0000X, 2085P0229X, 2085R0203X, 2085R0204X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0083811Medicaid
CAGR0083815Medicaid
CAZZZ75341ZMedicaid
CAGR0083810Medicaid
CAGR0083814Medicaid
CAGR0083812Medicaid
CAGR0083813Medicaid
CAGR0083816Medicaid
CAGR0083817Medicaid
CAGR0083812Medicaid
CATD009BMedicare PIN
CAGR0083813Medicaid
CAW529AMedicare PIN
A52865Medicare UPIN
CAGR0083814Medicaid
CATP110Medicare PIN
CATD009Medicare PIN
CAHW529AMedicare PIN
CAHW529Medicare PIN