Provider Demographics
NPI:1477601516
Name:OLIVER, DONALD C (OD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:C
Last Name:OLIVER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2664 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06610
Mailing Address - Country:US
Mailing Address - Phone:203-333-4828
Mailing Address - Fax:203-336-0049
Practice Address - Street 1:2664 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610
Practice Address - Country:US
Practice Address - Phone:203-333-4828
Practice Address - Fax:203-336-0049
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000674152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004023503Medicaid
410000191Medicare ID - Type Unspecified
T22743Medicare UPIN