Healthcare Provider Details

I. General information

NPI: 1265490429
Provider Name (Legal Business Name): JESSE M OLMEDO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 04/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14800 W MOUNTAIN VIEW BLVD SUITE 160
SURPRISE AZ
85374-2700
US

IV. Provider business mailing address

14800 W MOUNTAIN VIEW BLVD SUITE 160
SURPRISE AZ
85374-4795
US

V. Phone/Fax

Practice location:
  • Phone: 623-584-3376
  • Fax: 623-584-3375
Mailing address:
  • Phone: 623-584-3376
  • Fax: 623-584-3375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number30536
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: