Provider Demographics
NPI:1396199303
Name:RIVERA, VICTOR JUAN (MD)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:JUAN
Last Name:RIVERA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 W BASS ST
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-5001
Mailing Address - Country:US
Mailing Address - Phone:407-483-8801
Mailing Address - Fax:407-483-1298
Practice Address - Street 1:672 SW PRIMA VISTA BLVD STE 102
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-1820
Practice Address - Country:US
Practice Address - Phone:772-905-2560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-15
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR19320208D00000X
FLACN1144208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice