Healthcare Provider Details

I. General information

NPI: 1184376642
Provider Name (Legal Business Name): MYRTA ISABEL OLIVERA DUBON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2022
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1377 5TH AVE
BAY SHORE NY
11706-4131
US

IV. Provider business mailing address

1299 CORPORATE DR APT 1117
WESTBURY NY
11590-6643
US

V. Phone/Fax

Practice location:
  • Phone: 631-758-7003
  • Fax:
Mailing address:
  • Phone: 787-553-9029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number338825
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: