Provider Demographics
NPI:1235237744
Name:OLSEN, GORDON S (DOPC)
Entity type:Individual
Prefix:MR
First Name:GORDON
Middle Name:S
Last Name:OLSEN
Suffix:
Gender:M
Credentials:DOPC
Other - Prefix:
Other - First Name:GORDON
Other - Middle Name:S
Other - Last Name:OLSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DOPC
Mailing Address - Street 1:PO BOX 30180
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84130-0180
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:454 E MEDICAL WAY
Practice Address - Street 2:
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032-1391
Practice Address - Country:US
Practice Address - Phone:435-722-4691
Practice Address - Fax:435-722-9291
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2689281204207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY117765600Medicaid
G53879Medicare UPIN
WY10415Medicare ID - Type Unspecified