Provider Demographics
NPI:1245599976
Name:MERVEILLE, OCTAVE C (MD)
Entity type:Individual
Prefix:
First Name:OCTAVE
Middle Name:C
Last Name:MERVEILLE
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 1:6500 ABERDEEN RD
Mailing Address - Street 2:
Mailing Address - City:MISSION HILLS
Mailing Address - State:KS
Mailing Address - Zip Code:66208-1821
Mailing Address - Country:US
Mailing Address - Phone:913-384-0834
Mailing Address - Fax:
Practice Address - Street 1:4201 S HOCKER DR
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-4723
Practice Address - Country:US
Practice Address - Phone:913-384-0834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-15
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO33146208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice