Provider Demographics
NPI:1265530703
Name:WILLIAM A. OLIVOS, OD, PA
Entity type:Organization
Organization Name:WILLIAM A. OLIVOS, OD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:A
Authorized Official - Last Name:OLIVOS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:772-460-8487
Mailing Address - Street 1:4976 S 25TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34981-5009
Mailing Address - Country:US
Mailing Address - Phone:772-460-8487
Mailing Address - Fax:772-460-0225
Practice Address - Street 1:4976 S 25TH ST
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34981-4923
Practice Address - Country:US
Practice Address - Phone:772-460-8487
Practice Address - Fax:772-460-0225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 3500152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620569100Medicaid
FL5718990001OtherPALMETTO- DMERC
FL5718990001OtherPALMETTO- DMERC
FL5718990001Medicare NSC
FL20940Medicare PIN