Provider Demographics
NPI:1730278730
Name:OLIVER, MALCOLM B (MD)
Entity Type:Individual
Prefix:DR
First Name:MALCOLM
Middle Name:B
Last Name:OLIVER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1500 N OAKLAND
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613
Mailing Address - Country:US
Mailing Address - Phone:417-637-5133
Mailing Address - Fax:417-637-5124
Practice Address - Street 1:105 N GRAND
Practice Address - Street 2:SUITE 2
Practice Address - City:GREENFIELD
Practice Address - State:MO
Practice Address - Zip Code:65661
Practice Address - Country:US
Practice Address - Phone:417-637-5133
Practice Address - Fax:417-637-5124
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO107047207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207960519Medicaid
MOE17125Medicare UPIN