Provider Demographics
NPI:1508313701
Name:ACEVEDO ARUS, CARLOS OMAR
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:OMAR
Last Name:ACEVEDO ARUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:CARLOS
Other - Middle Name:OMAR
Other - Last Name:ACEVEDO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 781076 COLLEGE PARK
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-0001
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:2030 CHURCHMAN AVE
Practice Address - Street 2:
Practice Address - City:BEECH GROVE
Practice Address - State:IN
Practice Address - Zip Code:46107-1044
Practice Address - Country:US
Practice Address - Phone:317-786-9285
Practice Address - Fax:317-781-2793
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-06
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4956520390200000X
IN01089473A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program