Provider Demographics
NPI:1811069941
Name:LONDONO, JUAN CARLOS (DO)
Entity type:Individual
Prefix:DR
First Name:JUAN
Middle Name:CARLOS
Last Name:LONDONO
Suffix:
Gender:M
Credentials:DO
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:704-289-8427
Mailing Address - Fax:704-283-5522
Practice Address - Street 1:6824 HARRISBURG RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28227-3389
Practice Address - Country:US
Practice Address - Phone:704-870-6014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007-01119207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02332176Medicaid
NC5907835Medicaid
NC5907835Medicaid
NCNC2309AMedicare PIN
NYDD2632Medicare ID - Type Unspecified
NCNC2309BMedicare PIN