Provider Demographics
NPI:1902829898
Name:CAMILO, OSVALDO A (MD)
Entity Type:Individual
Prefix:
First Name:OSVALDO
Middle Name:A
Last Name:CAMILO
Suffix:
Gender:M
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-9437
Mailing Address - Fax:704-384-9440
Practice Address - Street 1:1918 RANDOLPH RD
Practice Address - Street 2:SUITE 400
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1100
Practice Address - Country:US
Practice Address - Phone:704-384-9437
Practice Address - Fax:704-384-9440
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3045152084N0400X
NC2004011802084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN01180Medicaid
NC5904399Medicaid
NC5904399Medicaid
SCN01180Medicaid