Provider Demographics
NPI:1154333920
Name:OLMEDO, MIGUEL (DNP)
Entity Type:Individual
Prefix:DR
First Name:MIGUEL
Middle Name:
Last Name:OLMEDO
Suffix:
Gender:M
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-1901
Mailing Address - Country:US
Mailing Address - Phone:508-856-0104
Mailing Address - Fax:
Practice Address - Street 1:605 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-1901
Practice Address - Country:US
Practice Address - Phone:508-856-0104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA212377363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY10141OtherGROUP #
MANP3358OtherBLUE CROSS BLUE SHIELD
MA1300709Medicaid
MAP35829Medicare Oscar/Certification
MANP3358OtherBLUE CROSS BLUE SHIELD
MA1300709Medicaid