Provider Demographics
NPI:1376734749
Name:RIVERA, ITZA M (MD)
Entity Type:Individual
Prefix:
First Name:ITZA
Middle Name:M
Last Name:RIVERA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ITZA
Other - Middle Name:M
Other - Last Name:RIVERA VELAZQUEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:720 ALMOND ST
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-3124
Mailing Address - Country:US
Mailing Address - Phone:352-404-6959
Mailing Address - Fax:
Practice Address - Street 1:720 ALMOND ST
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-3124
Practice Address - Country:US
Practice Address - Phone:352-404-6959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR17530208100000X, 2081N0008X
FLME1345582081N0008X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081N0008XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationNeuromuscular Medicine