Provider Demographics
NPI:1972579373
Name:MEDZIHRADSKY, OLIVER FELIX (MD)
Entity Type:Individual
Prefix:
First Name:OLIVER
Middle Name:FELIX
Last Name:MEDZIHRADSKY
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 1:1111 EMERALD BAY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6207
Mailing Address - Country:US
Mailing Address - Phone:530-543-5652
Mailing Address - Fax:530-541-8723
Practice Address - Street 1:2170 SOUTH AVENUE
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150
Practice Address - Country:US
Practice Address - Phone:530-542-3000
Practice Address - Fax:530-541-8723
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA93949207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A939490Medicaid
I50095Medicare UPIN
NVV102101Medicare PIN
CA00A939490Medicaid