Provider Demographics
NPI:1891975413
Name:OLSON FACIAL PLASTIC SURGERY, P.C.
Entity type:Organization
Organization Name:OLSON FACIAL PLASTIC SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEROLD
Authorized Official - Middle Name:J
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-200-2218
Mailing Address - Street 1:PO BOX 64307
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85728-4307
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6340 N CAMPBELL AVE STE 256
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718-3186
Practice Address - Country:US
Practice Address - Phone:520-200-2218
Practice Address - Fax:520-200-2935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-12
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ23526174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
23526OtherLICENSE
10776640OtherCAQH
1881745354OtherNPI
23526OtherLICENSE
E39481Medicare UPIN