Healthcare Provider Details

I. General information

NPI: 1770837320
Provider Name (Legal Business Name): MARIO LUIS OLIVENCIA MALAVE M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2012
Last Update Date: 07/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 CALLE DE DIEGO E STE 401
MAYAGUEZ PR
00680-5081
US

IV. Provider business mailing address

CPR PROFESIONAL BUILDING 65 DE DIEGO E.SUITE STE. 401
MAYAGUEZ PR
00680-8501
US

V. Phone/Fax

Practice location:
  • Phone: 787-487-7866
  • Fax:
Mailing address:
  • Phone: 787-805-1032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number20164
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: