Provider Demographics
NPI:1194839464
Name:RIVERA, ELIZABETH (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:
Last Name:RIVERA
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 1:6101 BLUE LAGOON DR STE 400
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-2051
Mailing Address - Country:US
Mailing Address - Phone:386-202-6025
Mailing Address - Fax:386-202-6025
Practice Address - Street 1:929 N SPRING GARDEN AVE STE 170
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-0917
Practice Address - Country:US
Practice Address - Phone:386-738-9144
Practice Address - Fax:386-738-9213
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME105694207Q00000X
PR7090207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRC79724Medicare UPIN
PR0028175Medicare ID - Type UnspecifiedMEDICARE PR