Basic Information
| Provider Information | |||||||||
| NPI: | 1144249624 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OCTAVIANI | ||||||||
| FirstName: | CLARYLEE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 S ORANGE AVE | ||||||||
| Address2: | STE 940 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328013221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076589687 | ||||||||
| FaxNumber: | 4076589688 | ||||||||
| Practice Location | |||||||||
| Address1: | 790 BUENAVENTURA BLVD | ||||||||
| Address2: | ORLANDO FAMILY PHYSICIANS | ||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347430000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073449959 | ||||||||
| FaxNumber: | 4073449971 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 02/01/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 14383 | PR | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RN0300X | ME128543 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 14,383 | 01 | PR | LICENCIA PR | OTHER | ME128543 | 01 | FL | FLORIDA LICENSE | OTHER |