Provider Demographics
NPI:1598815672
Name:OLIVIA M. GRAVES, M.D.,P.A.
Entity Type:Organization
Organization Name:OLIVIA M. GRAVES, M.D.,P.A.
Other - Org Name:PROMINADE PLAZA MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:OLIVIA
Authorized Official - Middle Name:MARGO
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-255-1355
Mailing Address - Street 1:11211 SW 152ND ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33157-1101
Mailing Address - Country:US
Mailing Address - Phone:305-255-1355
Mailing Address - Fax:305-255-2015
Practice Address - Street 1:11211 SW 152ND ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33157-1101
Practice Address - Country:US
Practice Address - Phone:305-255-1355
Practice Address - Fax:305-255-2015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME27434207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL92962Medicare ID - Type UnspecifiedMEDICARE