=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316032923
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIA M OLMEDA M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2006
-----------------------------------------------------
Last Update Date | 11/08/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1542 KINGSLEY AVE SUITE 140
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32073-4586
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-579-3189
-----------------------------------------------------
Fax | 904-458-4054
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1542 KINGSLEY AVE SUITE 140
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32073-4586
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-579-3189
-----------------------------------------------------
Fax | 904-458-4054
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 200401107
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 2001-275
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | ME122386
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------