Provider Demographics
NPI:1730403494
Name:OLSON, MATTHEW ROGER (DO)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ROGER
Last Name:OLSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18444 N 25TH AVE
Mailing Address - Street 2:310
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-1261
Mailing Address - Country:US
Mailing Address - Phone:866-974-2673
Mailing Address - Fax:866-939-2673
Practice Address - Street 1:18444 N 25TH AVE
Practice Address - Street 2:210
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85023-1261
Practice Address - Country:US
Practice Address - Phone:866-974-2673
Practice Address - Fax:866-939-2673
Is Sole Proprietor?:No
Enumeration Date:2010-03-23
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101018746208600000X
AZ006957207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery