Provider Demographics
NPI:1881038354
Name:OLIVA, BRENT STEVEN (DPM)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:STEVEN
Last Name:OLIVA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5925 N. MAIN ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-3142
Mailing Address - Country:US
Mailing Address - Phone:937-426-9500
Mailing Address - Fax:855-482-2339
Practice Address - Street 1:2207 OLYMPIC AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-2725
Practice Address - Country:US
Practice Address - Phone:937-426-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-26
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003776213ES0103X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery