Basic Information
| Provider Information | |||||||||
| NPI: | 1962898163 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OLIVAS | ||||||||
| FirstName: | JAIRO | ||||||||
| MiddleName: | MARTIN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3650 JOSEPH SIEWICK DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220331715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033912035 | ||||||||
| FaxNumber: | 7032649861 | ||||||||
| Practice Location | |||||||||
| Address1: | 3650 JOSEPH SIEWICK DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220331715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033912035 | ||||||||
| FaxNumber: | 7032649861 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2015 | ||||||||
| LastUpdateDate: | 10/17/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0101267656 | VA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | ME138665 | FL | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207QS0010X | 0101267656 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
No ID Information.