=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366780793
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDUARDO JOSE GARRIDO-GOICO MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2013
-----------------------------------------------------
Last Update Date | 04/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10340 PARK RD STE B
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28210-8401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 980-498-3900
-----------------------------------------------------
Fax | 888-489-2811
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10340 PARK RD STE B
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28210-8401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 980-498-3900
-----------------------------------------------------
Fax | 888-489-2811
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 2015-01686
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------