Provider Demographics
NPI:1770837320
Name:OLIVENCIA MALAVE, MARIO LUIS (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:LUIS
Last Name:OLIVENCIA MALAVE
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:CPR PROFESIONAL BUILDING 65 DE DIEGO E.SUITE STE. 401
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00680-8501
Mailing Address - Country:US
Mailing Address - Phone:787-805-1032
Mailing Address - Fax:
Practice Address - Street 1:55 CALLE DE DIEGO E STE 401
Practice Address - Street 2:
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680-5081
Practice Address - Country:US
Practice Address - Phone:787-487-7866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-05
Last Update Date:2017-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR20164208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR20164Medicare PIN