Healthcare Provider Details

I. General information

NPI: 1144326257
Provider Name (Legal Business Name): REBECCA E OLVERA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 04/19/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5708 EDWARDS RANCH RD
FORT WORTH TX
76109-4115
US

IV. Provider business mailing address

PO BOX 733784
DALLAS TX
75373-3784
US

V. Phone/Fax

Practice location:
  • Phone: 817-336-4040
  • Fax: 817-336-6780
Mailing address:
  • Phone: 682-885-1855
  • Fax: 682-885-1396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberK5647
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberK5647
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: