Provider Demographics
NPI:1023210804
Name:OCTAVIO CARRENO MD PA
Entity Type:Organization
Organization Name:OCTAVIO CARRENO MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ADKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-272-3200
Mailing Address - Street 1:2035 PROFESSIONAL CENTER DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4492
Mailing Address - Country:US
Mailing Address - Phone:904-272-3200
Mailing Address - Fax:904-272-3211
Practice Address - Street 1:2035 PROFESSIONAL CENTER DR
Practice Address - Street 2:SUITE A
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4492
Practice Address - Country:US
Practice Address - Phone:904-272-3200
Practice Address - Fax:904-272-3211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78105174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAC426Medicare PIN