Provider Demographics
NPI:1457465528
Name:OLIVERA, CHARLES HIRAM (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:HIRAM
Last Name:OLIVERA
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:PO BOX 4980
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00726-4980
Mailing Address - Country:US
Mailing Address - Phone:787-653-3108
Mailing Address - Fax:
Practice Address - Street 1:#100 AVE LUIS MUNOZ MARIN
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00725
Practice Address - Country:US
Practice Address - Phone:787-653-3434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 731032084N0400X
CODR.00590102084N0400X
AZ378682084N0400X
TXP47962084N0400X
PR125702084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRG57743Medicare UPIN