Provider Demographics
NPI:1417636549
Name:DORIVAL, TEDDY J
Entity Type:Individual
Prefix:
First Name:TEDDY
Middle Name:J
Last Name:DORIVAL
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:PO BOX 380373
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33238-0373
Mailing Address - Country:US
Mailing Address - Phone:305-842-0171
Mailing Address - Fax:
Practice Address - Street 1:12600 NW 19TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33167-2159
Practice Address - Country:US
Practice Address - Phone:305-842-0171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR001732-P.A.363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical