Provider Demographics
NPI:1700875788
Name:OLSEN, RANDALL V (MD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:V
Last Name:OLSEN
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 3242
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-3242
Mailing Address - Country:US
Mailing Address - Phone:844-295-4873
Mailing Address - Fax:844-839-0626
Practice Address - Street 1:1600 E BROADWAY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-5844
Practice Address - Country:US
Practice Address - Phone:573-815-8000
Practice Address - Fax:573-815-6343
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6035963-12052085B0100X, 2085D0003X, 2085R0202X
NV117712085R0202X
MO20170044672085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Neuroimaging
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
107044372101OtherIHC
UT870487570RDSOtherEMIA
MO1093702185Medicaid
UT870487570004Medicaid
UT60359631200001OtherBX
UT005242018Medicare PIN
UT870487570004Medicaid
MO103030008Medicare PIN
MO1093702185Medicaid