Healthcare Provider Details

I. General information

NPI: 1295938611
Provider Name (Legal Business Name): OMAR LAZARO ESPONDA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 06/19/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10660 PARK RD STE 3400
CHARLOTTE NC
28210-8461
US

IV. Provider business mailing address

10660 PARK RD STE 3400
CHARLOTTE NC
28210-8461
US

V. Phone/Fax

Practice location:
  • Phone: 704-667-3840
  • Fax: 704-468-0081
Mailing address:
  • Phone: 704-667-3840
  • Fax: 704-468-0081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number01484
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01484
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: