Provider Demographics
NPI:1821101478
Name:OLIVENCIA, JOSE A (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:A
Last Name:OLIVENCIA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2425 WESTOWN PKWY
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-1425
Mailing Address - Country:US
Mailing Address - Phone:515-222-8346
Mailing Address - Fax:515-222-0472
Practice Address - Street 1:2425 WESTOWN PKWY
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-1425
Practice Address - Country:US
Practice Address - Phone:515-222-8346
Practice Address - Fax:515-222-0472
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA19393208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
20015691OtherRAILROAD MEDICARE
6702OtherMIDLANDS CHOICE
02396OtherWELLMARK
NE10025355600Medicaid
IA1151837Medicaid
1700237OtherUNITED HEALTHCARE
663357OtherFIRST HEALTH
NE10025355600Medicaid
A01333Medicare UPIN