Provider Demographics
NPI:1164476420
Name:GOODISON-OLLIVIERRE, RENEE (DO)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:GOODISON-OLLIVIERRE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 GREEN ST E
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-4105
Mailing Address - Country:US
Mailing Address - Phone:252-243-9800
Mailing Address - Fax:
Practice Address - Street 1:303 GREEN ST E
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-4105
Practice Address - Country:US
Practice Address - Phone:252-243-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8171207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL263815100Medicaid
FLG99906Medicare UPIN
FL47867Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID