Provider Demographics
NPI:1265672778
Name:CLAVELL RIVERA, DIEGO G
Entity Type:Individual
Prefix:DR
First Name:DIEGO
Middle Name:G
Last Name:CLAVELL RIVERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6675 WESTWOOD BLVD STE 475
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32821-6027
Mailing Address - Country:US
Mailing Address - Phone:407-845-0330
Mailing Address - Fax:888-972-1752
Practice Address - Street 1:1044 PLAZA DR
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34743-4064
Practice Address - Country:US
Practice Address - Phone:407-350-5659
Practice Address - Fax:407-350-5662
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-23
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN542208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLACN542OtherMEDICINE DOCTOR LIC