Provider Demographics
NPI:1902368244
Name:LORUSSO VIVAS, GABRIELLA ANDREA (MD)
Entity Type:Individual
Prefix:
First Name:GABRIELLA
Middle Name:ANDREA
Last Name:LORUSSO VIVAS
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 1:1611 NW 12 AVE
Mailing Address - Street 2:HOLTZ CHILDREN'S HOSPITAL
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136
Mailing Address - Country:US
Mailing Address - Phone:305-585-6042
Mailing Address - Fax:305-545-6018
Practice Address - Street 1:1611 NW 12 AVENUE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136
Practice Address - Country:US
Practice Address - Phone:305-355-1122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-04
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FL29714390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program