Provider Demographics
NPI:1528028081
Name:RIVERO, LISSA V (OD)
Entity Type:Individual
Prefix:
First Name:LISSA
Middle Name:V
Last Name:RIVERO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 CATTLEMEN RD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34232-6243
Mailing Address - Country:US
Mailing Address - Phone:941-378-3937
Mailing Address - Fax:941-378-1868
Practice Address - Street 1:2020 CATTLEMEN RD.
Practice Address - Street 2:SUITE 500
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34232-6284
Practice Address - Country:US
Practice Address - Phone:941-378-3937
Practice Address - Fax:941-921-1741
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3664152W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620897500Medicaid
FL0928070001Medicare NSC
FLU01840Medicare PIN
FLU74206Medicare UPIN