Provider Demographics
NPI:1922392786
Name:DE LA RIVA MARCY, RACHEL ANN (OD)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:ANN
Last Name:DE LA RIVA MARCY
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 1:160 BOSTON AVE
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-4798
Mailing Address - Country:US
Mailing Address - Phone:407-775-7654
Mailing Address - Fax:407-834-6082
Practice Address - Street 1:5727 CANTON CV
Practice Address - Street 2:SUITE 111
Practice Address - City:WINTER SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32708-5033
Practice Address - Country:US
Practice Address - Phone:407-695-2020
Practice Address - Fax:407-699-5666
Is Sole Proprietor?:No
Enumeration Date:2011-06-08
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002618152W00000X
NY007641152W00000X
FLOPC4629152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004538300Medicaid
FL004538300Medicaid