Provider Demographics
NPI:1437517463
Name:OCTAVIANI MEDICINE PC
Entity Type:Organization
Organization Name:OCTAVIANI MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT - OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:OCTAVIANI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:315-703-3263
Mailing Address - Street 1:1223 N SALINA ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13208-1519
Mailing Address - Country:US
Mailing Address - Phone:315-703-3263
Mailing Address - Fax:
Practice Address - Street 1:1223 N SALINA ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13208-1519
Practice Address - Country:US
Practice Address - Phone:315-703-3263
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-04
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY197696207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty