Provider Demographics
NPI:1043434533
Name:RIVERA, MICHELLE LIZARDI (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:LIZARDI
Last Name:RIVERA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-2908
Mailing Address - Country:US
Mailing Address - Phone:904-296-0098
Mailing Address - Fax:
Practice Address - Street 1:7205 BONNEVAL RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-7565
Practice Address - Country:US
Practice Address - Phone:904-296-0098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG003127152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist