Provider Demographics
NPI:1962927038
Name:OLSEN, LAURA JO ZUKER (OD)
Entity type:Individual
Prefix:
First Name:LAURA JO
Middle Name:ZUKER
Last Name:OLSEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:JO
Other - Last Name:ZUKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:112 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PLAINVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06062-1944
Mailing Address - Country:US
Mailing Address - Phone:860-747-6443
Mailing Address - Fax:860-747-8019
Practice Address - Street 1:112 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PLAINVILLE
Practice Address - State:CT
Practice Address - Zip Code:06062-1944
Practice Address - Country:US
Practice Address - Phone:860-747-6443
Practice Address - Fax:860-747-8019
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-09
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003286152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAOD60883298OtherOD LICENSE
WAG9042998OtherMEDICARE