Provider Demographics
NPI:1053424101
Name:OLSON, KEVIN W (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:W
Last Name:OLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 25033
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92799-5033
Mailing Address - Country:US
Mailing Address - Phone:714-347-1000
Mailing Address - Fax:714-647-1245
Practice Address - Street 1:7901 FROST ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2701
Practice Address - Country:US
Practice Address - Phone:858-939-3400
Practice Address - Fax:858-939-4007
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG86467207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G864670Medicaid
CA00G864670OtherBLUE SHIELD OF CA
CAWG86467AMedicare PIN
CAF34703Medicare UPIN