=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730474735
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUAN OLIVARES JR. MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2011
-----------------------------------------------------
Last Update Date | 03/12/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5808 AIRLINE DR
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77076-4923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-695-4013
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3660 RICHMOND AVE APT 359
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77046-3604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-280-9919
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | N9617
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------