Provider Demographics
NPI:1336316546
Name:OLIVOS, JOSE L (OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:L
Last Name:OLIVOS
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11615 JAMAICA AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11418-2433
Mailing Address - Country:US
Mailing Address - Phone:718-847-9898
Mailing Address - Fax:718-847-9345
Practice Address - Street 1:11615 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418-2433
Practice Address - Country:US
Practice Address - Phone:718-847-9898
Practice Address - Fax:718-847-9345
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6871156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02687929Medicaid