Provider Demographics
NPI:1073094645
Name:DE OLIVEIRA, MARCEL (PTA)
Entity Type:Individual
Prefix:
First Name:MARCEL
Middle Name:
Last Name:DE OLIVEIRA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2937 OAK RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76054-2143
Mailing Address - Country:US
Mailing Address - Phone:469-278-2974
Mailing Address - Fax:
Practice Address - Street 1:2601 W RANDOL MILL RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012-4289
Practice Address - Country:US
Practice Address - Phone:469-278-2974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2086160225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2086160OtherMANAGED CARE
TX2086160Medicaid