Provider Demographics
NPI:1760468433
Name:OLIVER, LUIS ANTONIO (MD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:ANTONIO
Last Name:OLIVER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1804 CALLE JAJOME
Mailing Address - Street 2:URB. CROWN HILLS
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-6024
Mailing Address - Country:US
Mailing Address - Phone:787-763-0077
Mailing Address - Fax:
Practice Address - Street 1:402 MUNOZ RIVERA AVE.
Practice Address - Street 2:BASIC MEDICAL CLINIC
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00917
Practice Address - Country:US
Practice Address - Phone:787-767-3636
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3686208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics