Provider Demographics
NPI:1255359253
Name:OLIVERIO, MICHAEL FREDRICK (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:FREDRICK
Last Name:OLIVERIO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 JERUSALEM AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH BELLMORE
Mailing Address - State:NY
Mailing Address - Zip Code:11710-1832
Mailing Address - Country:US
Mailing Address - Phone:516-221-1173
Mailing Address - Fax:516-221-1180
Practice Address - Street 1:521 JERUSALEM AVE
Practice Address - Street 2:
Practice Address - City:NORTH BELLMORE
Practice Address - State:NY
Practice Address - Zip Code:11710-1832
Practice Address - Country:US
Practice Address - Phone:516-221-1173
Practice Address - Fax:516-221-1180
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210665204D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01955857Medicaid
NY01955857Medicaid
WEM791Medicare ID - Type Unspecified