Provider Demographics
NPI:1053425611
Name:OLSON, ERIC PETER (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:PETER
Last Name:OLSON
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 1:3430 WASHINGTON PKWY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404
Mailing Address - Country:US
Mailing Address - Phone:208-523-3060
Mailing Address - Fax:208-523-0028
Practice Address - Street 1:3430 WASHINGTON PARKWAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:208-523-3060
Practice Address - Fax:208-523-0028
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5358208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003870300Medicaid
ID53598OtherBLUE CROSS
ID000010006122OtherBLUE SHIELD
IDD65707Medicare UPIN
D65707Medicare UPIN