Provider Demographics
NPI:1861555195
Name:OLIVERAS, EDITH JENISSA (MD)
Entity type:Individual
Prefix:DR
First Name:EDITH
Middle Name:JENISSA
Last Name:OLIVERAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2410 E RIVERSIDE DR STE G3
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78741-3053
Mailing Address - Country:US
Mailing Address - Phone:512-448-3778
Mailing Address - Fax:512-448-3776
Practice Address - Street 1:2410 E RIVERSIDE DR STE G3
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78741-3053
Practice Address - Country:US
Practice Address - Phone:512-448-3778
Practice Address - Fax:512-448-3776
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4596208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX155187102Medicaid
TX153715105Medicaid
TX153715107Medicaid