Basic Information
| Provider Information | |||||||||
| NPI: | 1255534756 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OVIEDO | ||||||||
| FirstName: | ENRIQUE | ||||||||
| MiddleName: | IVAN | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 6705 EVANSTON RD | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212093865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102200780 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 40 S DUNDALK AVE STE 400 | ||||||||
| Address2: | |||||||||
| City: | DUNDALK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212224273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102200780 | ||||||||
| FaxNumber: | 4108620150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2007 | ||||||||
| LastUpdateDate: | 08/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | D0068379 | MD | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | D0068379 | 01 | MD | STATE LICENSE | OTHER | 445126100 | 05 | MD | MEDICAID |