Healthcare Provider Details

I. General information

NPI: 1396945028
Provider Name (Legal Business Name): MARIO ERNESTO OLMEDO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2007
Last Update Date: 09/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 HILLANDALE RD SUITE D
DURHAM NC
27705-2664
US

IV. Provider business mailing address

BOX 3886, DUMC 2100 ERWIN ROAD
DURHAM NC
27710
US

V. Phone/Fax

Practice location:
  • Phone: 919-383-4355
  • Fax:
Mailing address:
  • Phone: 919-684-6721
  • Fax: 919-668-1785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2007-01855
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: