Provider Demographics
NPI:1437437043
Name:OLIVA, STEPHANIE ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:ANN
Last Name:OLIVA
Suffix:
Gender:F
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:18969 US ROUTE 11
Mailing Address - Street 2:PO BOX 6600
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-6329
Mailing Address - Country:US
Mailing Address - Phone:315-782-4391
Mailing Address - Fax:315-782-4387
Practice Address - Street 1:18969 US ROUTE 11
Practice Address - Street 2:PEDIATRIC ASSOCIATES OF WATERTOWN
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-6329
Practice Address - Country:US
Practice Address - Phone:315-782-4391
Practice Address - Fax:315-782-4387
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-31
Last Update Date:2015-11-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0116023620208000000X
NY275269208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03987964Medicaid