1790806073 NPI number — JOHN ROBERT OVIEDO PT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790806073 NPI number — JOHN ROBERT OVIEDO PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OVIEDO
Provider First Name:
JOHN
Provider Middle Name:
ROBERT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

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:
1790806073
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
460 MALL BVLD
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
SAVANNAH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31406-3140
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-644-5300
Provider Business Mailing Address Fax Number:
912-644-5260

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 WEST MULBERRY BLVD
Provider Second Line Business Practice Location Address:
SUITE 140
Provider Business Practice Location Address City Name:
POOLER
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-748-5111
Provider Business Practice Location Address Fax Number:
912-748-6699
Provider Enumeration Date:
04/03/2007

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: 225100000X , with the licence number:  PT009856 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X , with the licence number: 9154 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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