Provider Demographics
NPI:1932852316
Name:OLVERA ANDRADE, JUAN JOSE (DPH)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:JOSE
Last Name:OLVERA ANDRADE
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3277 CYPRESS LN
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-0655
Mailing Address - Country:US
Mailing Address - Phone:918-931-1375
Mailing Address - Fax:
Practice Address - Street 1:4112 S PEORIA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-7613
Practice Address - Country:US
Practice Address - Phone:918-743-4491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17995183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist