1356304828 NPI number — DR. MIRIAM L RIVERA IRIZARRY M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356304828 NPI number — DR. MIRIAM L RIVERA IRIZARRY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RIVERA IRIZARRY
Provider First Name:
MIRIAM
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356304828
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/05/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 582170
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KISSIMMEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34758-0027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-343-5000
Provider Business Mailing Address Fax Number:
407-343-5199

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
339 CYPRESS PKWY STE 110
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KISSIMMEE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34759-3315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-343-5000
Provider Business Practice Location Address Fax Number:
407-343-5199
Provider Enumeration Date:
04/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  11914 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: ACN 295 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3280 . This is a "AMERICAN HEALTH" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 060075 . This is a "CRUZ AZUL" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 1101838 . This is a "ACAA" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 002357600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2968 . This is a "INTERNATIONAL MEDICAL CAR" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 0400684 . This is a "HUMANA HEALTH PLANS" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: MRI211 . This is a "MENONITA" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 88490 . This is a "TRIPLE S" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 212462 . This is a "PREFERRED HEALTH" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 400294 . This is a "MEDICARE Y MUCHO MAS" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 373955068 . This is a "PROSAM" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 105884100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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