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General NPI Number Information
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NPI Number | 1144452582
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Entity Type | Organization
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Legal Business Name | OP MEDICAL LLC
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Dates
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Enumeration Date | 08/19/2009
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Last Update Date | 08/19/2009
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Provider Practice Location Address
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Address Line | 1515 HERBERT ST STE 209
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City | PORT ORANGE
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State | FL
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Zip | 32129-6104
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Country | US
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Telephone | 386-366-9119
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Fax |
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Provider Business Mailing Address
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Address Line | 1515 HERBERT ST STE 209
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City | PORT ORANGE
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State | FL
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Zip | 32129-6104
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Country | US
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Telephone | 386-366-9119
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Fax |
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Authorized Official
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Title or Position | CLINIC DIRECTOR
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Name | DR. ANDREW JOSEPH OTTAVIANI
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Credential |
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Telephone | 386-366-9119
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208VP0014X
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Taxonomy Name | Interventional Pain Medicine Physician
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License Number | ME0067232
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License Number State | FL
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