Basic Information
| Provider Information | |||||||||
| NPI: | 1427244037 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OLSON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | RAY | ||||||||
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| Credential: | M.D., PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 45278 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322325278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042022092 | ||||||||
| FaxNumber: | 9043937603 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 PALM AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042027300 | ||||||||
| FaxNumber: | 9042027433 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2007 | ||||||||
| LastUpdateDate: | 11/12/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | A93245 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | ME104231 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 001151700 | 05 | FL | MEDICAID | P01330980 | 01 | FL | RR MEDICARE | OTHER |