Provider Demographics
NPI:1124102165
Name:HABACON, OLIVIA
Entity type:Individual
Prefix:DR
First Name:OLIVIA
Middle Name:
Last Name:HABACON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 MARCUS DR
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-4230
Mailing Address - Country:US
Mailing Address - Phone:631-391-8366
Mailing Address - Fax:631-454-4163
Practice Address - Street 1:9016 SUTPHIN BLVD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11435-3636
Practice Address - Country:US
Practice Address - Phone:718-523-5500
Practice Address - Fax:718-658-8260
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY142245208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00564627Medicaid
NY0105GDMedicare PIN
NY00564627Medicaid