Provider Demographics
NPI:1316019334
Name:OLIVA, STEPAN (MD)
Entity Type:Individual
Prefix:
First Name:STEPAN
Middle Name:
Last Name:OLIVA
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 1:560 AVENUE K SE
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-4203
Mailing Address - Country:US
Mailing Address - Phone:863-299-3376
Mailing Address - Fax:
Practice Address - Street 1:560 AVENUE K SE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-4203
Practice Address - Country:US
Practice Address - Phone:863-299-3376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME75639207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00397643OtherRAILROAD MEDICARE
FL43555OtherBLUE CROSS BLUE SHIELD OF FLORIDA
FL43555OtherBLUE CROSS BLUE SHIELD OF FLORIDA
FL20-5821881OtherEIN