Healthcare Provider Details

I. General information

NPI: 1679290910
Provider Name (Legal Business Name): LARA SOFIA OLIVER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2022
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 365067
SAN JUAN PR
00936-5067
US

IV. Provider business mailing address

PO BOX 365067
SAN JUAN PR
00936-5067
US

V. Phone/Fax

Practice location:
  • Phone: 787-505-9990
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number24475
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: