Provider Demographics
NPI:1053390229
Name:OLIVERAS, CARMEN (MD)
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:OLIVERAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CARMEN
Other - Middle Name:
Other - Last Name:OLIVERAS-CRESPO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4530 E MUIRWOOD DR STE 105
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-7693
Mailing Address - Country:US
Mailing Address - Phone:480-961-2303
Mailing Address - Fax:480-961-0419
Practice Address - Street 1:1955 W FRYE RD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-6282
Practice Address - Country:US
Practice Address - Phone:888-393-8674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-16
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ36855208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN183405300Medicaid
MN110008661Medicare ID - Type Unspecified
G38774Medicare UPIN
Z117621Medicare PIN
AZZ147678Medicare PIN