Healthcare Provider Details

I. General information

NPI: 1447454814
Provider Name (Legal Business Name): PEDRO OLMEDOCOLOR PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: PEDRO OLMEDO

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 E SOUTH ST SUITE 305
LAKEWOOD CA
90805-4549
US

IV. Provider business mailing address

3300 E SOUTH ST SUITE 305
LAKEWOOD CA
90805-4549
US

V. Phone/Fax

Practice location:
  • Phone: 562-622-8102
  • Fax: 562-622-6072
Mailing address:
  • Phone: 562-622-8102
  • Fax: 562-622-6072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 19056
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: