Healthcare Provider Details

I. General information

NPI: 1144249624
Provider Name (Legal Business Name): CLARYLEE OCTAVIANI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

766 N SUN DR STE 3030
LAKE MARY FL
32746-2555
US

IV. Provider business mailing address

2180 W SR 434 STE 1164
LONGWOOD FL
32779-5008
US

V. Phone/Fax

Practice location:
  • Phone: 407-444-2800
  • Fax: 407-444-2810
Mailing address:
  • Phone: 407-515-2211
  • Fax: 407-309-5412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberME128543
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: