MEDICARE: OCTAVIO DE JESUS AREVALO ESPEJO MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	U9819	TX
2	2085N0700X	Neuroradiology Physician	327970	LA

General Provider Information

NPI Number	:	1598253965
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OCTAVIO DE JESUS AREVALO ESPEJO MD

Provider Business Mailing Address
First Line	:	1512 W KIRBY PL
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71103-3822
Country	:	US
Telephone Number	:	318-626-0287
Fax Number	:	318-629-4808

Provider Business Practice Location Address
First Line	:	1541 KINGS HWY
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71103-4228
Country	:	US
Telephone Number	:	318-626-0000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2018
Last Update Date	:	12/10/2025

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