Provider Demographics
NPI:1326017658
Name:OLIVOS, WILLIAM A (OD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:A
Last Name:OLIVOS
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 1:4976 S 25TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34981-5009
Mailing Address - Country:US
Mailing Address - Phone:772-460-8487
Mailing Address - Fax:772-460-0225
Practice Address - Street 1:4976 S 25TH ST
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34981-5009
Practice Address - Country:US
Practice Address - Phone:772-460-8487
Practice Address - Fax:772-460-0225
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 3500152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002946000Medicaid
FL5718990001OtherPALMETTO-DMERC
FL002946001Medicaid
FL002946001Medicaid
5718990001Medicare NSC
FL620569100Medicaid