Provider Demographics
NPI:1609491497
Name:OLIVA, GERARDO
Entity Type:Individual
Prefix:
First Name:GERARDO
Middle Name:
Last Name:OLIVA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7141 SW 5TH CT
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33023-1008
Mailing Address - Country:US
Mailing Address - Phone:813-970-2211
Mailing Address - Fax:
Practice Address - Street 1:7141 SW 5TH CT
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33023-1008
Practice Address - Country:US
Practice Address - Phone:813-970-2211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-08
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRBT-20-117585Medicaid