Provider Demographics
NPI:1265490429
Name:OLMEDO, JESSE M (MD)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:M
Last Name:OLMEDO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:14800 W MOUNTAIN VIEW BLVD
Mailing Address - Street 2:SUITE 160
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-4795
Mailing Address - Country:US
Mailing Address - Phone:623-584-3376
Mailing Address - Fax:623-584-3375
Practice Address - Street 1:14800 W MOUNTAIN VIEW BLVD
Practice Address - Street 2:SUITE 160
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-2700
Practice Address - Country:US
Practice Address - Phone:623-584-3376
Practice Address - Fax:623-584-3375
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2014-04-09
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Provider Licenses
StateLicense IDTaxonomies
AZ30536207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1265490429OtherAHCCCS
AZ2281872OtherUNITED HEALTHCARE
AZ99S007000011OtherMEDISUN
AZ7538647OtherAETNA
AZ2Z3349OtherHEALTH NET
AZAZ0779550OtherBLUE CROSS BLUE SHIELD
AZ188961600OtherDEPT OF LABOR WORK COMP
AZP00234871OtherRAILROAD MEDICARE
H66084Medicare UPIN
AZ1265490429OtherAHCCCS
AZ101977Medicare PIN