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1265490429

NPI Code Detail

MEDICARE: JESSE M OLMEDO MD

MEDICARE: JESSE M OLMEDO MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	30536	AZ

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
8	P00234871	OTHER	AZ	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1265490429	OTHER	AZ	AHCCCS
2	2281872	OTHER	AZ	UNITED HEALTHCARE
3	99S007000011	OTHER	AZ	MEDISUN
4	7538647	OTHER	AZ	AETNA
5	2Z3349	OTHER	AZ	HEALTH NET
6	AZ0779550	OTHER	AZ	BLUE CROSS BLUE SHIELD
7	188961600	OTHER	AZ	DEPT OF LABOR WORK COMP

General Provider Information

NPI Number	:	1265490429
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSE M OLMEDO MD

Provider Business Mailing Address
First Line	:	14800 W MOUNTAIN VIEW BLVD
Second Line	:	SUITE 160
City	:	SURPRISE
State	:	AZ
Zip	:	85374-4795
Country	:	US
Telephone Number	:	623-584-3376
Fax Number	:	623-584-3375

Provider Business Practice Location Address
First Line	:	14800 W MOUNTAIN VIEW BLVD
Second Line	:	SUITE 160
City	:	SURPRISE
State	:	AZ
Zip	:	85374-2700
Country	:	US
Telephone Number	:	623-584-3376
Fax Number	:	623-584-3375

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/03/2006
Last Update Date	:	04/09/2014

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Practice Location Address:

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1750394227 — DR. DREW AUBREY REESE D.O.
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1992061162 — ARIZONA DERMATOLOGY SPECIALISTS, PLLC
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1164961157 — ELIZABETH V VESSELOVSKAYA PA-C
Practice Location Address:

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1740809615 — HAVILAH CHELSEA DODD PA-C
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Practice Phone: 623-584-3376
Practice Fax: 623-584-3375

Directions to “ JESSE M OLMEDO MD” Practice Location

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