1376734749 NPI number — ITZA M RIVERA MD

Table of content: ITZA M RIVERA MD (NPI 1376734749)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376734749 NPI number — ITZA M RIVERA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RIVERA
Provider First Name:
ITZA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RIVERA VELAZQUEZ
Provider Other First Name:
ITZA
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1376734749
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
720 ALMOND ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLERMONT
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34711-3124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-404-6959
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
720 ALMOND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLERMONT
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34711-3124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-404-6959
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/09/2007

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: 208100000X , with the licence number:  17530 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2081N0008X , with the licence number: ME134558 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2081N0008X , with the licence number: 17530 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208100000X , with the licence number: ME134558 , 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)