Provider Demographics
NPI:1023079621
Name:GAGOT-RIVERA, MIRZA IVELISSE (MD)
Entity type:Individual
Prefix:
First Name:MIRZA
Middle Name:IVELISSE
Last Name:GAGOT-RIVERA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MIRZA
Other - Middle Name:
Other - Last Name:GAGOT-RIVERA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:34 S BALDWIN AVE
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:FL
Mailing Address - Zip Code:34266-3387
Mailing Address - Country:US
Mailing Address - Phone:863-993-4601
Mailing Address - Fax:
Practice Address - Street 1:34 S BALDWIN AVE
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:FL
Practice Address - Zip Code:34266-3387
Practice Address - Country:US
Practice Address - Phone:863-993-4601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN224207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL56592OtherBLUE CROSS BLUE SHIELD
I18579Medicare UPIN
FL56592OtherBLUE CROSS BLUE SHIELD