Healthcare Provider Details

I. General information

NPI: 1700463346
Provider Name (Legal Business Name): DEVIN BUENNEMEYER MIJARES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2021
Last Update Date: 09/03/2025
Certification Date: 09/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1718 E 4TH ST STE 907
CHARLOTTE NC
28204-3282
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-372-4000
  • Fax: 704-334-4855
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2025-02284
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number303089
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: