Provider Demographics
NPI:1679661219
Name:OLAVIANY, THOMAS ALLEN (DPM)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:ALLEN
Last Name:OLAVIANY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:FORTY FORT
Mailing Address - State:PA
Mailing Address - Zip Code:18704-3937
Mailing Address - Country:US
Mailing Address - Phone:570-287-8887
Mailing Address - Fax:570-287-8914
Practice Address - Street 1:960 WYOMING AVE
Practice Address - Street 2:
Practice Address - City:FORTY FORT
Practice Address - State:PA
Practice Address - Zip Code:18704-3937
Practice Address - Country:US
Practice Address - Phone:570-287-8887
Practice Address - Fax:570-287-8914
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC003640L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U26455Medicare UPIN
PA683379Medicare ID - Type Unspecified