Provider Demographics
NPI:1376563189
Name:MANSILLA, OLIVIA A (MD)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:A
Last Name:MANSILLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KAROLIN
Other - Middle Name:
Other - Last Name:MANSILLA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:360 BROWN'S HILL CT..
Mailing Address - Street 2:MIDLOTHIAN
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:21114-9510
Mailing Address - Country:US
Mailing Address - Phone:804-379-3100
Mailing Address - Fax:804-379-3200
Practice Address - Street 1:360 BROWN'S HILL CT.
Practice Address - Street 2:MIDLOTHIAN
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23114-9510
Practice Address - Country:US
Practice Address - Phone:804-379-3100
Practice Address - Fax:804-379-3200
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101229981207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010021065Medicaid
VAC08725Medicare PIN