Provider Demographics
NPI:1245381136
Name:OLIVERSON, THOMAS JOHN
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:JOHN
Last Name:OLIVERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 840853
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0853
Mailing Address - Country:US
Mailing Address - Phone:972-233-1999
Mailing Address - Fax:972-233-3666
Practice Address - Street 1:1500 CITYWEST BLVD
Practice Address - Street 2:STE. 300
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77042
Practice Address - Country:US
Practice Address - Phone:713-620-4000
Practice Address - Fax:713-458-4229
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8152207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX169492903Medicaid
TX8AW2335OtherBLUE CROSS BLUE SHIELD
TX8B6004OtherOUT HARRIS - MEDICARE
TX169492902Medicaid
TX8K8602OtherBLUE CROSS
TXP00102257OtherRAILROAD - MEDICARE
LA1628913OtherLA - MEDICAID
H51528Medicare UPIN
P00102257Medicare PIN
TXP00102257OtherRAILROAD - MEDICARE
TX8K8885Medicare PIN