Provider Demographics
NPI:1396831665
Name:OLSON, JOHANNA LYNN (MD)
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:LYNN
Last Name:OLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1621 FAIR OAKS AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-4704
Mailing Address - Country:US
Mailing Address - Phone:323-399-1087
Mailing Address - Fax:323-399-1087
Practice Address - Street 1:1621 FAIR OAKS AVE
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-4704
Practice Address - Country:US
Practice Address - Phone:323-669-2153
Practice Address - Fax:323-913-3691
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2025-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA0673522080A0000X
CAA673522080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA67352AMedicare PIN
CAI51743Medicare UPIN