Provider Demographics
NPI:1700181195
Name:MADRID, OLIVER EVANGELISTA (PT)
Entity Type:Individual
Prefix:
First Name:OLIVER
Middle Name:EVANGELISTA
Last Name:MADRID
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 ARCADIA AVE APT 11
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91007-7112
Mailing Address - Country:US
Mailing Address - Phone:626-321-7076
Mailing Address - Fax:
Practice Address - Street 1:900 S 1ST AVE
Practice Address - Street 2:SUITE C
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91006-3919
Practice Address - Country:US
Practice Address - Phone:626-566-2750
Practice Address - Fax:626-566-2756
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-17
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35897225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist