Provider Demographics
NPI:1659554798
Name:EVARISTO E. RIVERO
Entity Type:Organization
Organization Name:EVARISTO E. RIVERO
Other - Org Name:THE FOOT DOCTOR CORPORATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EVARISTO
Authorized Official - Middle Name:E
Authorized Official - Last Name:RIVERO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:863-699-6001
Mailing Address - Street 1:230 E INTERLAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE PLACID
Mailing Address - State:FL
Mailing Address - Zip Code:33852-9603
Mailing Address - Country:US
Mailing Address - Phone:863-699-6001
Mailing Address - Fax:863-699-6002
Practice Address - Street 1:230 E INTERLAKE BLVD
Practice Address - Street 2:
Practice Address - City:LAKE PLACID
Practice Address - State:FL
Practice Address - Zip Code:33852-9603
Practice Address - Country:US
Practice Address - Phone:863-699-6001
Practice Address - Fax:863-699-6002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-12
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2506213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL390277300Medicaid
1158720001Medicare NSC
U59056Medicare UPIN
FL65414ZMedicare PIN