Provider Demographics
NPI:1053309674
Name:OLIVARES, ENRIQUE B (MD)
Entity Type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:B
Last Name:OLIVARES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:723 E PATAPSCO AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21225-1934
Mailing Address - Country:US
Mailing Address - Phone:410-355-1532
Mailing Address - Fax:
Practice Address - Street 1:723 E PATAPSCO AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21225-1934
Practice Address - Country:US
Practice Address - Phone:410-355-1532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDOO463132084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1500772OtherEVERCARE
MD677520900Medicaid
MD9895ROtherMD
MD677520900Medicaid
MD1500772OtherEVERCARE
DE491042Medicare ID - Type Unspecified
DC491042Medicare ID - Type Unspecified