Provider Demographics
NPI:1043211691
Name:RIVERO, EVARISTO ENRIQUE (DPM)
Entity Type:Individual
Prefix:DR
First Name:EVARISTO
Middle Name:ENRIQUE
Last Name:RIVERO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 E INTERLAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE PLACID
Mailing Address - State:FL
Mailing Address - Zip Code:33852-9603
Mailing Address - Country:US
Mailing Address - Phone:863-699-6001
Mailing Address - Fax:863-699-6002
Practice Address - Street 1:230 E INTERLAKE BLVD
Practice Address - Street 2:
Practice Address - City:LAKE PLACID
Practice Address - State:FL
Practice Address - Zip Code:33852-9603
Practice Address - Country:US
Practice Address - Phone:863-699-6001
Practice Address - Fax:863-699-6002
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-04
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO 2506213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL390277300Medicaid
FL390277300Medicaid
FL65414ZMedicare PIN
FL1158720001Medicare NSC