Provider Demographics
NPI:1538299094
Name:OLSON, ROBERT GEORGE (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:GEORGE
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:PO BOX 15876
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92659-5876
Mailing Address - Country:US
Mailing Address - Phone:949-218-4153
Mailing Address - Fax:949-218-4157
Practice Address - Street 1:361 HOSPITAL RD
Practice Address - Street 2:SUITE 124
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3522
Practice Address - Country:US
Practice Address - Phone:949-218-4153
Practice Address - Fax:949-218-4157
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG46852207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G468521OtherBLUE SHIELD
CA00G468520Medicaid
CAG46852AMedicare ID - Type Unspecified
CA00G468520Medicaid