Basic Information
| Provider Information | |||||||||
| NPI: | 1770656761 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MELENDEZ | ||||||||
| FirstName: | OCTAVIO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MELENDEZ-CABRERA | ||||||||
| OtherFirstName: | OCTAVIO | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 718 TEANECK ROAD | ||||||||
| Address2: | |||||||||
| City: | TEANECK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076660000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018337265 | ||||||||
| FaxNumber: | 2012276207 | ||||||||
| Practice Location | |||||||||
| Address1: | 419 66TH STREET | ||||||||
| Address2: | |||||||||
| City: | WEST NEW YORK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018619229 | ||||||||
| FaxNumber: | 2018619272 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 03/11/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 10122 | PR | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 25MA08597600 | NJ | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 210122 | 01 | MEDICAL CARD SYSTEM | OTHER | 600533 | 01 | MMM | OTHER | 1604287 | 01 | ACCA | OTHER | 2062 | 01 | INTERNATIONAL MEDICAL CAR | OTHER | 1218 | 01 | AMERICAN HEALTH INC | OTHER | 7310178 | 01 | HUMANA | OTHER | 7310178 | 01 | HUMANA REFORMA | OTHER | 62875 | 01 | CRUZ AZUL | OTHER | 7310178 | 01 | HUMANA HEALTH CARE | OTHER | 3710122 | 01 | AUTORIDAD DE ACUEDUCTOS | OTHER |