Provider Demographics
NPI:1467567933
Name:OLIVER, LARRY D (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:D
Last Name:OLIVER
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 28007
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97228-8007
Mailing Address - Country:US
Mailing Address - Phone:844-540-8736
Mailing Address - Fax:602-798-8267
Practice Address - Street 1:3302 W GOLF COURSE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79703-5110
Practice Address - Country:US
Practice Address - Phone:432-522-2304
Practice Address - Fax:432-522-2307
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1867207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1304602-05Medicaid
110159822OtherRAILROAD MEDICARE
TX130460205Medicaid
TXF1867OtherTEXAS MEDICAL LICENSE
110159822OtherRAILROAD MEDICARE
86X380Medicare PIN