Healthcare Provider Details

I. General information

NPI: 1508313701
Provider Name (Legal Business Name): CARLOS OMAR ACEVEDO ARUS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: CARLOS OMAR ACEVEDO MD

II. Dates (important events)

Enumeration Date: 09/06/2016
Last Update Date: 07/19/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2030 CHURCHMAN AVE
BEECH GROVE IN
46107-1044
US

IV. Provider business mailing address

PO BOX 781076 COLLEGE PARK
DETROIT MI
48278-0001
US

V. Phone/Fax

Practice location:
  • Phone: 317-786-9285
  • Fax: 317-781-2793
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4956520
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01089473A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: