Provider Demographics
NPI:1891227625
Name:RIVEROS, DIEGO ALEXANDER
Entity Type:Individual
Prefix:
First Name:DIEGO
Middle Name:ALEXANDER
Last Name:RIVEROS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6860 30TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-3002
Mailing Address - Country:US
Mailing Address - Phone:352-260-2226
Mailing Address - Fax:
Practice Address - Street 1:1 TAMPA GENERAL CIR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-3571
Practice Address - Country:US
Practice Address - Phone:813-844-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-30
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV29727207P00000X
PAMD470775207P00000X
FLME138836207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine