Healthcare Provider Details

I. General information

NPI: 1346371994
Provider Name (Legal Business Name): MARIO M OLIVEIRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1519 E BOULDER ST
COLORADO SPRINGS CO
80909-5663
US

IV. Provider business mailing address

1519 E BOULDER ST
COLORADO SPRINGS CO
80909-5663
US

V. Phone/Fax

Practice location:
  • Phone: 719-632-5155
  • Fax: 719-632-5595
Mailing address:
  • Phone: 719-632-5155
  • Fax: 719-632-5595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number23688
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: