Provider Demographics
NPI:1811081763
Name:OLIVER, RICHARD D (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:D
Last Name:OLIVER
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 1:22-18 BROADWAY
Mailing Address - Street 2:SUITE 104
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-1552
Mailing Address - Country:US
Mailing Address - Phone:201-797-4503
Mailing Address - Fax:201-797-4270
Practice Address - Street 1:22-18 BROADWAY
Practice Address - Street 2:SUITE 104
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-1552
Practice Address - Country:US
Practice Address - Phone:201-797-4503
Practice Address - Fax:201-797-4270
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2018-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03505200207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2843102Medicaid
NJC60885Medicare UPIN