Healthcare Provider Details

I. General information

NPI: 1629039409
Provider Name (Legal Business Name): OCTAVIO DE JESUS CARRENO M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 09/14/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 SW 62ND AVE STE 124
MIAMI FL
33155
US

IV. Provider business mailing address

3100 SW 62ND AVE. STE 124
MIAMI FL
33155
US

V. Phone/Fax

Practice location:
  • Phone: 305-662-8316
  • Fax: 305-663-8513
Mailing address:
  • Phone: 305-662-8316
  • Fax: 305-663-8513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License NumberME78105
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: