1144208000 NPI number — DR. OLIVIA BRIDGET MIJUMBI MD

Table of content: DR. OLIVIA BRIDGET MIJUMBI MD (NPI 1144208000)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144208000 NPI number — DR. OLIVIA BRIDGET MIJUMBI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIJUMBI
Provider First Name:
OLIVIA
Provider Middle Name:
BRIDGET
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NANZIRI
Provider Other First Name:
OLIVIA
Provider Other Middle Name:
BRIDGET
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1144208000
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/01/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 550818
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GASTONIA
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28055-0818
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-864-0303
Provider Business Mailing Address Fax Number:
704-864-6070

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
239 WILMOT DR STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GASTONIA
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28054-4048
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-864-0303
Provider Business Practice Location Address Fax Number:
704-864-6070
Provider Enumeration Date:
01/02/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  9701818 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 810561334 . This is a "WELLPATH SELECT INC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 810561334 . This is a "HEALTHNET OF CA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 9259849 . This is a "PHCS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 810561334 . This is a "SOUTHCARE PPO INC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: A8078 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 12-01098 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1322Y . This is a "BLUECROSS BLUESHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 810561334 . This is a "PRIMARY PHYSCIAIN CARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 810561334 . This is a "HEALTHCARE SAVINGS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 810561334 . This is a "NORTH AMERICA ADMIN LP" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 2900124 . This is a "AETNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 810561334 . This is a "TRICARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 810561334 . This is a "ONE HEALTH" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 9554744001 . This is a "CIGNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 891322Y , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1322Y . This is a "STATE HEALTH PLAN NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 810561334 . This is a "HEALTHSOURCE OF NC" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 810561334 . This is a "PREMIER HEALTH SYSTEMS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".