Provider Demographics
NPI:1528202280
Name:OLIVEROS, MYRA CALONGCAGONG (PT)
Entity Type:Individual
Prefix:MRS
First Name:MYRA
Middle Name:CALONGCAGONG
Last Name:OLIVEROS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18075 TOMPKINS CT
Mailing Address - Street 2:
Mailing Address - City:DUMFRIES
Mailing Address - State:VA
Mailing Address - Zip Code:22026-2477
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11 DAIRY LN
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22405-2663
Practice Address - Country:US
Practice Address - Phone:540-371-9414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-25
Last Update Date:2009-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305205351208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation