Provider Demographics
NPI:1467897975
Name:VIVAR, SUSSI (MD)
Entity Type:Individual
Prefix:
First Name:SUSSI
Middle Name:
Last Name:VIVAR
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 1:11513 LAKE UNDERHILL RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-5001
Mailing Address - Country:US
Mailing Address - Phone:407-249-1234
Mailing Address - Fax:407-249-1755
Practice Address - Street 1:1651 N SEMORAN BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32807-3575
Practice Address - Country:US
Practice Address - Phone:407-249-1234
Practice Address - Fax:407-249-1755
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-10
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME128202208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017692800Medicaid