Provider Demographics
NPI:1710415492
Name:OLIVERIO MEDICAL CORPORATION
Entity Type:Organization
Organization Name:OLIVERIO MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:OLIVERIO
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:951-849-1950
Mailing Address - Street 1:330 W RAMSEY ST
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220-4823
Mailing Address - Country:US
Mailing Address - Phone:951-849-1950
Mailing Address - Fax:951-849-1892
Practice Address - Street 1:330 W RAMSEY ST
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-4823
Practice Address - Country:US
Practice Address - Phone:951-849-1950
Practice Address - Fax:951-849-1892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45042207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty