Provider Demographics
NPI:1114221801
Name:DE LA RIVA, MICHELLE ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ELIZABETH
Last Name:DE LA RIVA
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 1:7400 DOCS GROVE CIR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-8010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7400 DOCS GROVE CIR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-8010
Practice Address - Country:US
Practice Address - Phone:407-352-9717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-10
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY262700207R00000X
NJ25MA08990800207R00000X
FLME113642207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLGV826ZMedicare PIN