Provider Demographics
NPI:1992411805
Name:RIVERA, ANGEL LUIS
Entity type:Individual
Prefix:
First Name:ANGEL
Middle Name:LUIS
Last Name:RIVERA
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 1:3772 EAGLE ISLE CIR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34746-1907
Mailing Address - Country:US
Mailing Address - Phone:321-333-2573
Mailing Address - Fax:
Practice Address - Street 1:216 BROADWAY
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-5768
Practice Address - Country:US
Practice Address - Phone:407-910-4040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-24
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME121469208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice