Provider Demographics
NPI:1770656761
Name:MELENDEZ, OCTAVIO (MD)
Entity Type:Individual
Prefix:
First Name:OCTAVIO
Middle Name:
Last Name:MELENDEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:OCTAVIO
Other - Middle Name:
Other - Last Name:MELENDEZ-CABRERA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:718 TEANECK ROAD
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-0000
Mailing Address - Country:US
Mailing Address - Phone:201-833-7265
Mailing Address - Fax:201-227-6207
Practice Address - Street 1:419 66TH STREET
Practice Address - Street 2:
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093
Practice Address - Country:US
Practice Address - Phone:201-861-9229
Practice Address - Fax:201-861-9272
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR10122207V00000X
NJ25MA08597600207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
210122OtherMEDICAL CARD SYSTEM
600533OtherMMM
1604287OtherACCA
2062OtherINTERNATIONAL MEDICAL CAR
1218OtherAMERICAN HEALTH INC
7310178OtherHUMANA
7310178OtherHUMANA REFORMA
62875OtherCRUZ AZUL
7310178OtherHUMANA HEALTH CARE
3710122OtherAUTORIDAD DE ACUEDUCTOS
600533OtherMMM
7310178OtherHUMANA REFORMA