Provider Demographics
NPI:1912653361
Name:OCTAVE, ELYSE
Entity Type:Individual
Prefix:
First Name:ELYSE
Middle Name:
Last Name:OCTAVE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2724 N HIAWASSEE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32818-3008
Mailing Address - Country:US
Mailing Address - Phone:407-906-0082
Mailing Address - Fax:407-604-2606
Practice Address - Street 1:2724 N HIAWASSEE RD STE 100
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32818-3008
Practice Address - Country:US
Practice Address - Phone:407-906-0082
Practice Address - Fax:407-604-2606
Is Sole Proprietor?:No
Enumeration Date:2022-02-24
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME152754207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine