Healthcare Provider Details

I. General information

NPI: 1235392309
Provider Name (Legal Business Name): HUMBERTO JOSE OLIVERO LARA MD, MSPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: HUMBERTO JOSE OLIVERO L. MD, MSPH

II. Dates (important events)

Enumeration Date: 07/08/2008
Last Update Date: 11/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 WEST MAIN STREET
FREDERICKTOWN MO
63645
US

IV. Provider business mailing address

611 WEST MAIN STREET
FREDERICKTOWN MO
63645
US

V. Phone/Fax

Practice location:
  • Phone: 573-783-3341
  • Fax: 573-783-1096
Mailing address:
  • Phone: 573-783-3341
  • Fax: 573-783-1096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number2014025224
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number2014025224
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code202C00000X
TaxonomyIndependent Medical Examiner Physician
License Number2014025224
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2014025224
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: