Provider Demographics
NPI:1891439618
Name:OLIVERA GONZALEZ, SERGIO ANTONIO (SA-C)
Entity Type:Individual
Prefix:
First Name:SERGIO
Middle Name:ANTONIO
Last Name:OLIVERA GONZALEZ
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1428 SW 14TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33145-1543
Mailing Address - Country:US
Mailing Address - Phone:786-669-1056
Mailing Address - Fax:
Practice Address - Street 1:1428 SW 14TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33145-1543
Practice Address - Country:US
Practice Address - Phone:786-669-1056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-27
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21-763246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant