Provider Demographics
NPI:1093778029
Name:OLIVER, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:OLIVER
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 871988
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99687-1988
Mailing Address - Country:US
Mailing Address - Phone:907-357-6121
Mailing Address - Fax:907-357-6171
Practice Address - Street 1:3750 E COUNTRY FIELD CIR STE D
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6659
Practice Address - Country:US
Practice Address - Phone:907-357-6121
Practice Address - Fax:907-357-6171
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4950207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK160059561OtherMEDICARE RAILROAD
AK954332081OtherTAX ID
AKMD5356Medicaid