Provider Demographics
NPI:1720489446
Name:RIVERA MIRABAL, JORGE LUIS
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:LUIS
Last Name:RIVERA MIRABAL
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 1:41 W KALEY ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2942
Mailing Address - Country:US
Mailing Address - Phone:407-843-6645
Mailing Address - Fax:407-843-4519
Practice Address - Street 1:41 W KALEY ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2942
Practice Address - Country:US
Practice Address - Phone:407-843-6645
Practice Address - Fax:407-843-4519
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-12
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10056345208600000X, 208800000X
FLME153764208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No208600000XAllopathic & Osteopathic PhysiciansSurgery