Provider Demographics
NPI:1790369304
Name:OLIVERA, SAMILLE ANGELICA (MD)
Entity Type:Individual
Prefix:
First Name:SAMILLE
Middle Name:ANGELICA
Last Name:OLIVERA
Suffix:
Gender:F
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:KM 37.5 AVENIDA PONCE DE LEON
Mailing Address - Street 2:
Mailing Address - City:HATO REY
Mailing Address - State:PR
Mailing Address - Zip Code:00919
Mailing Address - Country:US
Mailing Address - Phone:787-758-2000
Mailing Address - Fax:
Practice Address - Street 1:BO MONACILLO
Practice Address - Street 2:CENTRO MEDICO DE PUERTO RICO
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00928
Practice Address - Country:US
Practice Address - Phone:787-480-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-10
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR22812208D00000X
PR15726-I390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty