Healthcare Provider Details

I. General information

NPI: 1588651632
Provider Name (Legal Business Name): EDUARDO J. OLMEDO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 01/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2041 MESA VALLEY WAY SUITE 100
AUSTELL GA
30106-8157
US

IV. Provider business mailing address

2041 MESA VALLEY WAY SUITE 100
AUSTELL GA
30106-8157
US

V. Phone/Fax

Practice location:
  • Phone: 770-944-1100
  • Fax: 770-944-6469
Mailing address:
  • Phone: 770-944-1100
  • Fax: 770-944-6469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number034036
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: