Provider Demographics
NPI:1144452582
Name:OP MEDICAL LLC
Entity type:Organization
Organization Name:OP MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:OTTAVIANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-366-9119
Mailing Address - Street 1:1515 HERBERT ST
Mailing Address - Street 2:STE 209
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-6104
Mailing Address - Country:US
Mailing Address - Phone:386-366-9119
Mailing Address - Fax:
Practice Address - Street 1:1515 HERBERT ST
Practice Address - Street 2:STE 209
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-6104
Practice Address - Country:US
Practice Address - Phone:386-366-9119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-19
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0067232208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty