Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RA0401X | Internist - Addiction Medicine | ME0076599 | FL |
NPI | 1316012743 |
---|---|
Provider Name | Dr. Carmen C Vivero |
First Address | St Augustine, FL 32080-3108 |
Second Address | St Augustine, FL 32080-3108 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/11/2006 |
Last Update Date | 19/08/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
281237100 | (05) | FL |
44784 | BLUE CROSS BLUE SHIELD (01) | FL |
C82601 | (02) | FL |
DN9360 | RR MEDICARE (01) | FL |