Provider Demographics
NPI:1457436685
Name:DE OLARTE, GLORIA (MD)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:
Last Name:DE OLARTE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 N MADISON AVE STE 406
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-2049
Mailing Address - Country:US
Mailing Address - Phone:626-577-7965
Mailing Address - Fax:626-577-4625
Practice Address - Street 1:65 N MADISON AVE STE 406
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-2049
Practice Address - Country:US
Practice Address - Phone:626-577-7965
Practice Address - Fax:626-577-4625
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA35537174400000X, 2082S0099X, 2082S0105X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No174400000XOther Service ProvidersSpecialist
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and Neck
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA35537OtherLICENCE
CA1558542076OtherNPI
CA953661841OtherTAX ID
CAAD9322265OtherDEA
CA1558542076OtherNPI