Provider Demographics
NPI:1295938611
Name:ESPONDA, OMAR LAZARO (MD)
Entity type:Individual
Prefix:DR
First Name:OMAR
Middle Name:LAZARO
Last Name:ESPONDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:10660 PARK RD STE 3400
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-8461
Mailing Address - Country:US
Mailing Address - Phone:704-667-3840
Mailing Address - Fax:704-468-0081
Practice Address - Street 1:10660 PARK RD STE 3400
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8461
Practice Address - Country:US
Practice Address - Phone:704-667-3840
Practice Address - Fax:704-468-0081
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC01484202K00000X, 207R00000X
NY274587207R00000X
FL123442207R00000X
OK29407207R00000X
PR18004207R00000X, 246XC2903X
246XC2903X
18004246XC2903X
FLME1234422086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No246XC2903XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularVascular Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400132897OtherMEDICARE PTAN
NY04318732Medicaid