Provider Demographics
NPI:1346371994
Name:OLIVEIRA, MARIO M (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:M
Last Name:OLIVEIRA
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 1:1519 E BOULDER ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-5663
Mailing Address - Country:US
Mailing Address - Phone:719-632-5155
Mailing Address - Fax:719-632-5595
Practice Address - Street 1:1519 E BOULDER ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5663
Practice Address - Country:US
Practice Address - Phone:719-632-5155
Practice Address - Fax:719-632-5595
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23688204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
COD24308Medicare UPIN
COCO458568Medicare ID - Type Unspecified