Healthcare Provider Details

I. General information

NPI: 1932852316
Provider Name (Legal Business Name): JUAN JOSE OLVERA ANDRADE DPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2022
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 E MAIN ST
HULBERT OK
74441-8901
US

IV. Provider business mailing address

3277 CYPRESS LN
TAHLEQUAH OK
74464-0655
US

V. Phone/Fax

Practice location:
  • Phone: 918-772-2727
  • Fax: 918-772-6131
Mailing address:
  • Phone: 918-931-1375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number17995
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: