Provider Demographics
NPI:1598253965
Name:AREVALO ESPEJO, OCTAVIO DE JESUS (MD)
Entity Type:Individual
Prefix:
First Name:OCTAVIO DE JESUS
Middle Name:
Last Name:AREVALO ESPEJO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1512 W KIRBY PL
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3822
Mailing Address - Country:US
Mailing Address - Phone:318-626-0287
Mailing Address - Fax:318-629-4808
Practice Address - Street 1:1541 KINGS HWY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-626-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-01
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3279702085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology