Provider Demographics
NPI:1235133588
Name:OLIVER, TRAVIS L (OD)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:L
Last Name:OLIVER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9058 GRACIE LN
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-5363
Mailing Address - Country:US
Mailing Address - Phone:901-218-3353
Mailing Address - Fax:
Practice Address - Street 1:8400 US HIGHWAY 64
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38133-4187
Practice Address - Country:US
Practice Address - Phone:901-381-1222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2008-07-03
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
TN2176152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNU91433Medicare UPIN
TN3945269Medicare ID - Type UnspecifiedMEDICARE ID