Healthcare Provider Details

I. General information

NPI: 1144208000
Provider Name (Legal Business Name): OLIVIA BRIDGET MIJUMBI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: OLIVIA BRIDGET NANZIRI MD

II. Dates (important events)

Enumeration Date: 01/02/2006
Last Update Date: 02/01/2023
Certification Date: 02/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

239 WILMOT DR STE A
GASTONIA NC
28054-4048
US

IV. Provider business mailing address

PO BOX 550818
GASTONIA NC
28055-0818
US

V. Phone/Fax

Practice location:
  • Phone: 704-864-0303
  • Fax: 704-864-6070
Mailing address:
  • Phone: 704-864-0303
  • Fax: 704-864-6070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number9701818
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: