Doctor Name: | MARIO LUIS OLIVENCIA |
NPI Number: | 1770837320 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | M.D |
License Number: | 20164 |
Business Practice Address: | 55 Calle De Diego E Ste 401 Mayaguez, PR - 006805081 |
Business Phone Number: | 7874877866 |
Business Fax Number: | |
Mailing Address: | Cpr Profesional Building 65 De Diego E.suite Ste. 401, MAYAGUEZ |
State: | PR |
Postal Code: | 006808501 |
Phone Number: | 7878051032 |
Fax Number: | |
NPI Enumeration Date: | 11/05/2012 |
NPI Last Update Date: | 11/05/2012 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 208D00000X |
License Number: | 20164 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | PR |
Taxonomy Type: | Allopathic & Osteopathic Physicians |
Taxonomy Classification: | General Practice |
Taxonomy Specialization: | |
Taxonomy Definition: |