Healthcare Provider Details

I. General information

NPI: 1477257137
Provider Name (Legal Business Name): JADTHIEL OLIVA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2023
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8745 N WICKHAM RD
MELBOURNE FL
32940-5997
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 321-434-1771
  • Fax: 321-434-1775
Mailing address:
  • Phone: 321-434-1771
  • Fax: 321-434-1775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME180779
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: