Provider Demographics
NPI:1033632203
Name:TOBAR, OCTAVIO ANDRES
Entity Type:Individual
Prefix:
First Name:OCTAVIO
Middle Name:ANDRES
Last Name:TOBAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 BARRETT LAKES BLVD NW APT 1213
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-7535
Mailing Address - Country:US
Mailing Address - Phone:813-447-0124
Mailing Address - Fax:
Practice Address - Street 1:1950 BARRETT LAKES BLVD NW APT 1213
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144
Practice Address - Country:US
Practice Address - Phone:813-447-0124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-19
Last Update Date:2018-08-20
Deactivation Date:2017-12-05
Deactivation Code:
Reactivation Date:2018-07-31
Provider Licenses
StateLicense IDTaxonomies
FLAL41962255A2300X
GAAT0033352255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAAT003335OtherSECRETARY OF STATE
FLAL4196OtherFLORIDA DEPARTMENT OF HEALTH