Healthcare Provider Details

I. General information

NPI: 1114922077
Provider Name (Legal Business Name): LUIS F. OLMEDO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 07/27/2023
Certification Date: 07/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

817 VOLVO PKWY
CHESAPEAKE VA
23320-2855
US

IV. Provider business mailing address

817 VOLVO PKWY
CHESAPEAKE VA
23320-2855
US

V. Phone/Fax

Practice location:
  • Phone: 757-668-4630
  • Fax:
Mailing address:
  • Phone: 757-668-4630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number6155
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number6155
License Number StatePR
# 3
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number0101255330
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101255330
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: