Provider Demographics
NPI:1386153237
Name:OLIVER, DEREK
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:OLIVER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1108
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91358-0108
Mailing Address - Country:US
Mailing Address - Phone:805-300-1242
Mailing Address - Fax:
Practice Address - Street 1:300 HILLMONT AVE
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-1651
Practice Address - Country:US
Practice Address - Phone:805-652-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-22
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54952363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant