Provider Demographics
NPI:1841286325
Name:OCTAVIANI, DENISE (DO)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:OCTAVIANI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7999 AUSTRIAN PINE CIR
Mailing Address - Street 2:
Mailing Address - City:MANLIUS
Mailing Address - State:NY
Mailing Address - Zip Code:13104-9372
Mailing Address - Country:US
Mailing Address - Phone:315-703-3263
Mailing Address - Fax:315-425-1994
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:315-425-1994
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-21
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY197696-1207QA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01604911Medicaid
NY01604911Medicaid
NYG18629Medicare UPIN