Provider Demographics
NPI:1437290327
Name:QUIJOTE, OCTAVIO JR (PT)
Entity type:Individual
Prefix:MR
First Name:OCTAVIO
Middle Name:
Last Name:QUIJOTE
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6812 37TH RD
Mailing Address - Street 2:APT.# 601
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-2864
Mailing Address - Country:US
Mailing Address - Phone:646-703-4461
Mailing Address - Fax:
Practice Address - Street 1:6812 37TH RD
Practice Address - Street 2:APT.# 601
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-2864
Practice Address - Country:US
Practice Address - Phone:646-703-4461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016035225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist