Provider Demographics
NPI:1952588188
Name:RIVAS, JOSE EMILIANO (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:EMILIANO
Last Name:RIVAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOSE
Other - Middle Name:EMILIANO
Other - Last Name:RIVAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1113 LATTIMORE DR
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-9032
Mailing Address - Country:US
Mailing Address - Phone:941-779-4870
Mailing Address - Fax:
Practice Address - Street 1:9938 UNIVERSAL BLVD STE 102
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-8705
Practice Address - Country:US
Practice Address - Phone:407-615-5844
Practice Address - Fax:407-930-9232
Is Sole Proprietor?:No
Enumeration Date:2008-01-30
Last Update Date:2015-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 121469208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL13663196OtherCAQH
FLPENDINGMedicare PIN