1316032923 NPI number — DR. MARIA M OLMEDA M.D.

Table of content: DR. MARIA M OLMEDA M.D. (NPI 1316032923)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316032923 NPI number — DR. MARIA M OLMEDA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OLMEDA
Provider First Name:
MARIA
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316032923
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1542 KINGSLEY AVE
Provider Second Line Business Mailing Address:
SUITE 140
Provider Business Mailing Address City Name:
ORANGE PARK
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32073-4586
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-579-3189
Provider Business Mailing Address Fax Number:
904-458-4054

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1542 KINGSLEY AVE
Provider Second Line Business Practice Location Address:
SUITE 140
Provider Business Practice Location Address City Name:
ORANGE PARK
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32073-4586
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-579-3189
Provider Business Practice Location Address Fax Number:
904-458-4054
Provider Enumeration Date:
10/03/2006

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: 207RG0100X , with the licence number:  200401107 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: 2001-275 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: ME122386 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000G262 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 891374H , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 839467 . This is a "AHCCCS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 014961100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1374H . This is a "BLUE CROSS BLUE SHEILD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 111496700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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