Provider Demographics
NPI:1083646913
Name:RIVERA SANTIAGO, MAYRA (MD)
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:
Last Name:RIVERA SANTIAGO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38135 MARKET SQ
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33542-7505
Mailing Address - Country:US
Mailing Address - Phone:813-528-4975
Mailing Address - Fax:
Practice Address - Street 1:17417 BRIDGEHILL CT,
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-2308
Practice Address - Country:US
Practice Address - Phone:813-972-7900
Practice Address - Fax:813-355-5035
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME79661207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL260874000Medicaid
FLP00133424OtherRR MEDICARE
FL58635YMedicare PIN
FL260874000Medicaid