Provider Demographics
NPI:1063591915
Name:OLIVERIO, MICHAEL RAYMUND JR (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RAYMUND
Last Name:OLIVERIO
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 W RAMSEY ST
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220-4823
Mailing Address - Country:US
Mailing Address - Phone:951-849-1950
Mailing Address - Fax:
Practice Address - Street 1:330 W RAMSEY ST
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-4823
Practice Address - Country:US
Practice Address - Phone:951-849-1950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45042207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A450420Medicaid
CAAO3196Medicare UPIN
CAZZZ33480ZMedicare ID - Type Unspecified