Basic Information
| Provider Information | |||||||||
| NPI: | 1790369304 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OLIVERA | ||||||||
| FirstName: | SAMILLE | ||||||||
| MiddleName: | ANGELICA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | KM 37.5 AVENIDA PONCE DE LEON | ||||||||
| Address2: | |||||||||
| City: | HATO REY | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877582000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | AVENIDA PONCE DE LEON STOP 37.5 | ||||||||
| Address2: | |||||||||
| City: | HATO REY | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877582000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2021 | ||||||||
| LastUpdateDate: | 05/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 15726-I | PR | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.