Provider Demographics
NPI:1447268198
Name:OLSON, LEATRICE (DO)
Entity type:Individual
Prefix:
First Name:LEATRICE
Middle Name:
Last Name:OLSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9943 HICKMAN RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:URBANDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50322-5304
Mailing Address - Country:US
Mailing Address - Phone:515-248-1447
Mailing Address - Fax:515-248-1440
Practice Address - Street 1:3509 E 29TH ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50317-4253
Practice Address - Country:US
Practice Address - Phone:515-248-1600
Practice Address - Fax:515-248-1610
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01876207Q00000X
IADO-01876207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2218511Medicaid
IAI99090051OtherMEDICARE PTAN
IAA02502Medicare UPIN
IAI99090051OtherMEDICARE PTAN