Basic Information
| Provider Information | |||||||||
| NPI: | 1396945028 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OLMEDO | ||||||||
| FirstName: | MARIO | ||||||||
| MiddleName: | ERNESTO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | BOX 3886, DUMC | ||||||||
| Address2: | 2100 ERWIN ROAD | ||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196846721 | ||||||||
| FaxNumber: | 9196681785 | ||||||||
| Practice Location | |||||||||
| Address1: | 1901 HILLANDALE RD | ||||||||
| Address2: | SUITE D | ||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277052664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193834355 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2007 | ||||||||
| LastUpdateDate: | 09/19/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2007-01855 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5909827 | 05 | NC | MEDICAID |