Provider Demographics
NPI:1730172438
Name:OLSEN, STEPHEN J (OD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:J
Last Name:OLSEN
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 1:466 2ND ST
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-3127
Mailing Address - Country:US
Mailing Address - Phone:503-636-6900
Mailing Address - Fax:503-636-2985
Practice Address - Street 1:466 2ND ST
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034-3127
Practice Address - Country:US
Practice Address - Phone:503-636-6900
Practice Address - Fax:503-636-2985
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1934T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORU59419Medicare UPIN
OR136202Medicare PIN