Provider Demographics
NPI:1255534756
Name:OVIEDO, ENRIQUE IVAN (MD)
Entity type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:IVAN
Last Name:OVIEDO
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 1:6705 EVANSTON RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-3865
Mailing Address - Country:US
Mailing Address - Phone:410-220-0780
Mailing Address - Fax:
Practice Address - Street 1:40 S DUNDALK AVE STE 400
Practice Address - Street 2:
Practice Address - City:DUNDALK
Practice Address - State:MD
Practice Address - Zip Code:21222-4273
Practice Address - Country:US
Practice Address - Phone:410-220-0780
Practice Address - Fax:410-862-0150
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00683792084P0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDD0068379OtherSTATE LICENSE
MD445126100Medicaid