Provider Demographics
NPI:1124139183
Name:OLIVER, DAMON T (PT)
Entity type:Individual
Prefix:MR
First Name:DAMON
Middle Name:T
Last Name:OLIVER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 CRYSTAL LAKE RD
Mailing Address - Street 2:
Mailing Address - City:ASPEN
Mailing Address - State:CO
Mailing Address - Zip Code:81611-2255
Mailing Address - Country:US
Mailing Address - Phone:970-920-5827
Mailing Address - Fax:970-925-4879
Practice Address - Street 1:1450 CRYSTAL LAKE RD
Practice Address - Street 2:
Practice Address - City:ASPEN
Practice Address - State:CO
Practice Address - Zip Code:81611-2255
Practice Address - Country:US
Practice Address - Phone:970-920-5827
Practice Address - Fax:970-925-4879
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7841225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO533848Medicare ID - Type UnspecifiedPROV #
CO342748Medicare ID - Type UnspecifiedGRP #