Provider Demographics
NPI:1013758994
Name:OLIVER SEGARRA, JOSE L
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:L
Last Name:OLIVER SEGARRA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BDA MARIANI CALLE WILSON 1933
Mailing Address - Street 2:
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00717
Mailing Address - Country:US
Mailing Address - Phone:787-420-9267
Mailing Address - Fax:
Practice Address - Street 1:611 AVE ANDALUCIA
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00920-5310
Practice Address - Country:US
Practice Address - Phone:787-626-6164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-04
Last Update Date:2025-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PR003529122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program