Provider Demographics
NPI:1295721496
Name:DE LA RIVA, RAFAEL (MD)
Entity type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
Last Name:DE LA RIVA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4519 GEORGE RD
Mailing Address - Street 2:STE. 100
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-7329
Mailing Address - Country:US
Mailing Address - Phone:813-496-1075
Mailing Address - Fax:
Practice Address - Street 1:17240 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-8978
Practice Address - Country:US
Practice Address - Phone:352-754-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME49426207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00117872Medicare PIN
FL02278YMedicare PIN