Provider Demographics
NPI:1053625020
Name:OLIVEROS, EDMUND DE CASTRO (PT)
Entity type:Individual
Prefix:
First Name:EDMUND
Middle Name:DE CASTRO
Last Name:OLIVEROS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 OLD MAMARONECK RD
Mailing Address - Street 2:APT 4-G
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10605-1745
Mailing Address - Country:US
Mailing Address - Phone:914-821-7625
Mailing Address - Fax:
Practice Address - Street 1:3 OLD MAMARONECK RD
Practice Address - Street 2:APT 4-G
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10605-1745
Practice Address - Country:US
Practice Address - Phone:914-821-7625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-02
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015969225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist