Provider Demographics
NPI:1447293212
Name:GONCALVES, OCTAVIO (CRNA)
Entity type:Individual
Prefix:MR
First Name:OCTAVIO
Middle Name:
Last Name:GONCALVES
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 TIMBER LN
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:CT
Mailing Address - Zip Code:06524-3365
Mailing Address - Country:US
Mailing Address - Phone:203-623-1612
Mailing Address - Fax:
Practice Address - Street 1:1450 CHAPEL ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-4405
Practice Address - Country:US
Practice Address - Phone:203-789-3540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT073600367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT430001161Medicare ID - Type Unspecified