Provider Demographics
NPI:1730151861
Name:OLSEN, SCOTT FREDERIC (MD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:FREDERIC
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 1:3349 NIBLICK DR
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-5889
Mailing Address - Country:US
Mailing Address - Phone:702-521-6768
Mailing Address - Fax:
Practice Address - Street 1:3349 NIBLICK DR
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-5889
Practice Address - Country:US
Practice Address - Phone:702-521-6768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6689207L00000X
UT185861-1205207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2019419Medicaid
NV05WCHDF29Medicare ID - Type Unspecified
NV2019419Medicaid