Provider Demographics
NPI:1295935104
Name:OLIVERIO, BROCK JOSEPH (MD)
Entity type:Individual
Prefix:DR
First Name:BROCK
Middle Name:JOSEPH
Last Name:OLIVERIO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:327 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-9006
Mailing Address - Country:US
Mailing Address - Phone:681-342-1610
Mailing Address - Fax:681-342-1626
Practice Address - Street 1:327 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-9006
Practice Address - Country:US
Practice Address - Phone:681-342-1610
Practice Address - Fax:681-342-1626
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-19
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV22630207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV4255651OtherMEDICARE PTAN