Provider Demographics
NPI:1023005378
Name:OLIVO, DOMINICK (DPM)
Entity Type:Individual
Prefix:DR
First Name:DOMINICK
Middle Name:
Last Name:OLIVO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:ME
Mailing Address - Zip Code:04457-4000
Mailing Address - Country:US
Mailing Address - Phone:207-794-6700
Mailing Address - Fax:207-794-6389
Practice Address - Street 1:175 W BROADWAY
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:ME
Practice Address - Zip Code:04457-4000
Practice Address - Country:US
Practice Address - Phone:207-794-6700
Practice Address - Fax:207-794-6389
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT151213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000390660Medicaid
MT00083088Medicare ID - Type Unspecified
MT0000390660Medicaid