Provider Demographics
NPI:1992992432
Name:RIVERA-VEGA, MICHELLE Y (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:Y
Last Name:RIVERA-VEGA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 W GORE ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1141
Mailing Address - Country:US
Mailing Address - Phone:321-843-1182
Mailing Address - Fax:321-841-3305
Practice Address - Street 1:60 W GORE ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1141
Practice Address - Country:US
Practice Address - Phone:321-843-1182
Practice Address - Fax:321-841-3305
Is Sole Proprietor?:No
Enumeration Date:2007-09-28
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC167414208000000X, 2080P0205X
FLME1202522080P0205X, 208000000X
FLME1651492080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012696700Medicaid