Provider Demographics
NPI:1073775466
Name:OLIVER, JOHN ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ANDREW
Last Name:OLIVER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:130 RIVER CLUB CIR
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-9725
Mailing Address - Country:US
Mailing Address - Phone:870-816-3890
Mailing Address - Fax:870-816-0773
Practice Address - Street 1:1801 MARTIN LUTHER KING JR DR
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:AR
Practice Address - Zip Code:72342-8998
Practice Address - Country:US
Practice Address - Phone:662-588-9914
Practice Address - Fax:866-782-0773
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-27
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS208272085R0202X
ARE77892085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02875302Medicaid
AR201873001Medicaid
AR327932ZQL4Medicare PIN