Provider Demographics
NPI:1164036844
Name:OLIVARES, EDGARDO YABIR (MT)
Entity Type:Individual
Prefix:
First Name:EDGARDO
Middle Name:YABIR
Last Name:OLIVARES
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5818 BEVERLYHILL ST STE 100
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77057-6710
Mailing Address - Country:US
Mailing Address - Phone:832-358-5500
Mailing Address - Fax:
Practice Address - Street 1:4700 E RIVERSIDE DR APT 1418
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78741-4767
Practice Address - Country:US
Practice Address - Phone:832-358-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX112354225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist