Provider Demographics
NPI:1184778516
Name:OLIVOS, VICTOR HUGO (OPHTHALMIC DISPENSER)
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:HUGO
Last Name:OLIVOS
Suffix:
Gender:M
Credentials:OPHTHALMIC DISPENSER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7508 37TH AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-6538
Mailing Address - Country:US
Mailing Address - Phone:718-476-1458
Mailing Address - Fax:718-476-1462
Practice Address - Street 1:7508 37TH AVE
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-6538
Practice Address - Country:US
Practice Address - Phone:718-476-1458
Practice Address - Fax:718-476-1462
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC003703-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00335882Medicaid
NY00335882Medicaid