1659693612 NPI number — DR. ANDREA DOLORES OLIVAS M.D.

Table of content: DR. ANDREA DOLORES OLIVAS M.D. (NPI 1659693612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659693612 NPI number — DR. ANDREA DOLORES OLIVAS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OLIVAS
Provider First Name:
ANDREA
Provider Middle Name:
DOLORES
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659693612
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/06/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
180 HARVESTER DR
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
BURR RIDGE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60527-7594
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-702-1150
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5841 S MARYLAND AVE
Provider Second Line Business Practice Location Address:
MC 3083
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60637-1447
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-834-8376
Provider Business Practice Location Address Fax Number:
773-702-1119
Provider Enumeration Date:
02/18/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X , with the licence number:  036.124896 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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