Provider Demographics
NPI:1003900689
Name:OCTAVIANI-REYES, MELBA E (MD)
Entity Type:Individual
Prefix:
First Name:MELBA
Middle Name:E
Last Name:OCTAVIANI-REYES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9320 ROOSEVELT AVE # A
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-7911
Mailing Address - Country:US
Mailing Address - Phone:718-404-9109
Mailing Address - Fax:
Practice Address - Street 1:7224 BERGENLINE AVE
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-5417
Practice Address - Country:US
Practice Address - Phone:201-869-4603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14,814208000000X
NY262778208000000X
NJ25MA07711600208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03539879Medicaid