Provider Demographics
NPI:1629039409
Name:CARRENO, OCTAVIO DE JESUS (MD)
Entity Type:Individual
Prefix:
First Name:OCTAVIO
Middle Name:DE JESUS
Last Name:CARRENO
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 1:3100 SW 62ND AVE.
Mailing Address - Street 2:STE 124
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155
Mailing Address - Country:US
Mailing Address - Phone:305-662-8316
Mailing Address - Fax:305-663-8513
Practice Address - Street 1:3100 SW 62ND AVE
Practice Address - Street 2:STE 124
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155
Practice Address - Country:US
Practice Address - Phone:305-662-8316
Practice Address - Fax:305-663-8513
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78105207YX0007X, 163WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WX0200XNursing Service ProvidersRegistered NurseOncology
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432628999Medicaid
0002803Medicare PIN
ME000280301Medicare PIN
ME432628999Medicaid