Provider Demographics
NPI:1033615133
Name:RIVERO ORTEGA, MAILIN
Entity Type:Individual
Prefix:
First Name:MAILIN
Middle Name:
Last Name:RIVERO ORTEGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:975 BAPTIST WAY
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33033-7600
Mailing Address - Country:US
Mailing Address - Phone:786-270-4699
Mailing Address - Fax:786-576-0471
Practice Address - Street 1:11750 BIRD RD
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-3530
Practice Address - Country:US
Practice Address - Phone:305-223-2000
Practice Address - Fax:305-227-5556
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-05
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME149097207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program