Provider Demographics
NPI:1669179164
Name:OLVIDO, JERALD (MT)
Entity type:Individual
Prefix:
First Name:JERALD
Middle Name:
Last Name:OLVIDO
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9027 SUMMER GROVE CV
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-7498
Mailing Address - Country:US
Mailing Address - Phone:901-832-2191
Mailing Address - Fax:
Practice Address - Street 1:7945 WOLF RIVER BLVD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1762
Practice Address - Country:US
Practice Address - Phone:901-683-0055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-14
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN22601246RM2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical LaboratoryGroup - Multi-Specialty