Provider Demographics
NPI:1316012743
Name:VIVERO, CARMEN C (MD)
Entity Type:Individual
Prefix:DR
First Name:CARMEN
Middle Name:C
Last Name:VIVERO
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:1301 PLANTATION ISLAND DR S
Mailing Address - Street 2:SUITE 402-B
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-3108
Mailing Address - Country:US
Mailing Address - Phone:904-460-0707
Mailing Address - Fax:904-460-0727
Practice Address - Street 1:1301 PLANTATION ISLAND DR S
Practice Address - Street 2:SUITE 402-B
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-3108
Practice Address - Country:US
Practice Address - Phone:904-460-0707
Practice Address - Fax:904-460-0727
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME0076599207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL281237100Medicaid
FLDN9360OtherRR MEDICARE
FL44784OtherBLUE CROSS BLUE SHIELD
FLC82601Medicare UPIN
FL281237100Medicaid