Basic Information
| Provider Information | |||||||||
| NPI: | 1467567933 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OLIVER | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 28007 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972288007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8445408736 | ||||||||
| FaxNumber: | 6027988267 | ||||||||
| Practice Location | |||||||||
| Address1: | 3302 W GOLF COURSE RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MIDLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797035110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4325222304 | ||||||||
| FaxNumber: | 4325222307 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 11/18/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | F1867 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RN0300X | F1867 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 1304602-05 | 05 | TX | MEDICAID | 110159822 | 01 | RAILROAD MEDICARE | OTHER | 130460205 | 05 | TX | MEDICAID | F1867 | 01 | TX | TEXAS MEDICAL LICENSE | OTHER |