Provider Demographics
NPI:1053495218
Name:OLIVERAS GOTAY, JOFGREK (MD)
Entity Type:Individual
Prefix:
First Name:JOFGREK
Middle Name:
Last Name:OLIVERAS GOTAY
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:PO BOX 800073
Mailing Address - Street 2:
Mailing Address - City:COTO LAUREL
Mailing Address - State:PR
Mailing Address - Zip Code:00780-0073
Mailing Address - Country:US
Mailing Address - Phone:787-840-3470
Mailing Address - Fax:787-840-3470
Practice Address - Street 1:344 URB LAS MONJITAS CALLE NOVICIA
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00730
Practice Address - Country:US
Practice Address - Phone:787-843-3838
Practice Address - Fax:787-843-3838
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13784208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR83939Medicare ID - Type Unspecified
PRL-04312Medicare UPIN