Provider Demographics
NPI:1629084272
Name:OLIVARES, MELQUIADES JR (MD,)
Entity Type:Individual
Prefix:DR
First Name:MELQUIADES
Middle Name:
Last Name:OLIVARES
Suffix:JR
Gender:M
Credentials:MD,
Other - Prefix:DR
Other - First Name:MEL
Other - Middle Name:
Other - Last Name:OLIVARES
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:260 MILLS AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-4125
Mailing Address - Country:US
Mailing Address - Phone:505-425-6731
Mailing Address - Fax:505-454-9193
Practice Address - Street 1:260 MILLS AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4125
Practice Address - Country:US
Practice Address - Phone:505-425-6731
Practice Address - Fax:505-454-9193
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM90265208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00042138Medicaid
NM00042138Medicaid