Provider Demographics
NPI:1386825131
Name:ACEVEDO, TANIA MIMI (MD)
Entity Type:Individual
Prefix:DR
First Name:TANIA
Middle Name:MIMI
Last Name:ACEVEDO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1845
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28687-1845
Mailing Address - Country:US
Mailing Address - Phone:704-873-4277
Mailing Address - Fax:
Practice Address - Street 1:1818 DAVIE AVE
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677
Practice Address - Country:US
Practice Address - Phone:704-873-1036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-21
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011007275207R00000X, 208M00000X
NC2015-00788207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1386825131Medicaid
MO1386825131Medicaid
MO139000058Medicare PIN