Provider Demographics
NPI:1497910905
Name:RIVERA SERRANO, CARLOS MARIO (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:MARIO
Last Name:RIVERA SERRANO
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 1:1111 KANE CONCOURSE STE 111
Mailing Address - Street 2:
Mailing Address - City:BAY HARBOR ISLANDS
Mailing Address - State:FL
Mailing Address - Zip Code:33154-2039
Mailing Address - Country:US
Mailing Address - Phone:617-755-9404
Mailing Address - Fax:
Practice Address - Street 1:1111 KANE CONCOURSE STE 111
Practice Address - Street 2:
Practice Address - City:BAY HARBOR ISLANDS
Practice Address - State:FL
Practice Address - Zip Code:33154-2039
Practice Address - Country:US
Practice Address - Phone:617-755-9404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.1392592086S0122X
FLME1486292086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214881Medicare Oscar/Certification