Provider Demographics
NPI:1417163791
Name:MIRABAL, ALICIA RIVERA (MD)
Entity Type:Individual
Prefix:MRS
First Name:ALICIA
Middle Name:RIVERA
Last Name:MIRABAL
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 1:2130 SW 143RD PL
Mailing Address - Street 2:MIAMI, FL 33175
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-8027
Mailing Address - Country:US
Mailing Address - Phone:305-331-2965
Mailing Address - Fax:
Practice Address - Street 1:10200 NW 25TH ST STE 114
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33172-5919
Practice Address - Country:US
Practice Address - Phone:305-594-6505
Practice Address - Fax:305-594-6591
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME86920208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME0086920Medicare ID - Type UnspecifiedFLORIDA MEDICARE