Provider Demographics
NPI:1962075358
Name:WILLIAM A OLIVOS OD PA
Entity type:Organization
Organization Name:WILLIAM A OLIVOS OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:A
Authorized Official - Last Name:OLIVOS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:772-460-8487
Mailing Address - Street 1:2710 SW PORT ST LUCIE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-2849
Mailing Address - Country:US
Mailing Address - Phone:772-460-8487
Mailing Address - Fax:772-460-0225
Practice Address - Street 1:2710 SW PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-2849
Practice Address - Country:US
Practice Address - Phone:772-460-8487
Practice Address - Fax:772-460-0225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-22
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002946001Medicaid