Provider Demographics
NPI:1821020942
Name:OBESO, VIVIAN T (MD)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:T
Last Name:OBESO
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 1:1500 NW 12TH AVE
Mailing Address - Street 2:JMT-EAST 1007
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1028
Mailing Address - Country:US
Mailing Address - Phone:305-243-4664
Mailing Address - Fax:305-243-3787
Practice Address - Street 1:1611 NW 12TH AVE
Practice Address - Street 2:BOX 016960 M851
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1005
Practice Address - Country:US
Practice Address - Phone:305-585-1111
Practice Address - Fax:305-243-3787
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87993207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2676737-00Medicaid
FL2676737-00Medicaid
H93801Medicare UPIN