Provider Demographics
NPI:1144264904
Name:OLSSON, JAY EDWARD (DO PROF ASSOCIATIONN)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:EDWARD
Last Name:OLSSON
Suffix:
Gender:M
Credentials:DO PROF ASSOCIATIONN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 N WICKHAM RD
Mailing Address - Street 2:SUITE S
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-8659
Mailing Address - Country:US
Mailing Address - Phone:321-242-9031
Mailing Address - Fax:321-242-9035
Practice Address - Street 1:401 N WICKHAM RD
Practice Address - Street 2:SUITE S
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-8659
Practice Address - Country:US
Practice Address - Phone:321-242-9031
Practice Address - Fax:321-242-9035
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0004087208100000X
FLOS4087208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL045794900Medicaid
FL82948AMedicare ID - Type Unspecified
FL045794900Medicaid