Basic Information
| Provider Information | |||||||||
| NPI: | 1447268198 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OLSON | ||||||||
| FirstName: | LEATRICE | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9943 HICKMAN RD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | URBANDALE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503225304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152481447 | ||||||||
| FaxNumber: | 5152481440 | ||||||||
| Practice Location | |||||||||
| Address1: | 3509 E 29TH ST | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503174253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152481600 | ||||||||
| FaxNumber: | 5152481610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 09/10/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01876 | IA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | DO-01876 | IA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2218511 | 05 | IA | MEDICAID | I99090051 | 01 | IA | MEDICARE PTAN | OTHER |