Provider Demographics
NPI:1710185301
Name:OLIVER, MARK ALLAN (DPT, ATC, CSCS, CPED)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLAN
Last Name:OLIVER
Suffix:
Gender:M
Credentials:DPT, ATC, CSCS, CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111B SANDERS LN
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:24605-9278
Mailing Address - Country:US
Mailing Address - Phone:276-326-3611
Mailing Address - Fax:276-322-2850
Practice Address - Street 1:111B SANDERS LN
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:VA
Practice Address - Zip Code:24605-9278
Practice Address - Country:US
Practice Address - Phone:276-326-3611
Practice Address - Fax:276-322-2850
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-05
Last Update Date:2015-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV0025672251S0007X
VA23052024182251X0800X
VA0501020532255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0156094000Medicaid
WV0156094000Medicaid