Provider Demographics
NPI:1245284892
Name:OLIVOS, GUILLERMO (MD)
Entity type:Individual
Prefix:
First Name:GUILLERMO
Middle Name:
Last Name:OLIVOS
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 1:324 GANNETT DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-3266
Mailing Address - Country:US
Mailing Address - Phone:207-482-7800
Mailing Address - Fax:
Practice Address - Street 1:489 STATE ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6616
Practice Address - Country:US
Practice Address - Phone:207-973-8150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD168172085R0202X, 207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDCD4495Medicare ID - Type UnspecifiedRAILROAD MEDICARE
MDCN2566Medicare ID - Type UnspecifiedRAILROAD MEDICARE
DEDD4343Medicare ID - Type UnspecifiedRAILROAD MEDICARE
MD115991700Medicaid
MD435LK704Medicare ID - Type UnspecifiedLOCALITY/JURIS. CODE 02
MD016138A00Medicare ID - Type UnspecifiedLOCALITY/JURIS. CODE 99
MD434LK951Medicare ID - Type UnspecifiedLOCALITY/JURIS. CODE 01