Healthcare Provider Details

I. General information

NPI: 1164425682
Provider Name (Legal Business Name): MARIO S CLAROS-OLIVA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2005
Last Update Date: 07/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 S TYLER ST
COVINGTON LA
70433
US

IV. Provider business mailing address

120 INNWOOD DR
COVINGTON LA
70433-9123
US

V. Phone/Fax

Practice location:
  • Phone: 985-898-4000
  • Fax:
Mailing address:
  • Phone: 985-892-3225
  • Fax: 985-234-0628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number022838
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: