Basic Information
| Provider Information | |||||||||
| NPI: | 1265672778 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLAVELL RIVERA | ||||||||
| FirstName: | DIEGO | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6675 WESTWOOD BLVD STE 475 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328216027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078450330 | ||||||||
| FaxNumber: | 8889721752 | ||||||||
| Practice Location | |||||||||
| Address1: | 1044 PLAZA DR | ||||||||
| Address2: | |||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347434064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073505659 | ||||||||
| FaxNumber: | 4073505662 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2009 | ||||||||
| LastUpdateDate: | 09/20/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | ACN542 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | ACN542 | 01 | FL | MEDICINE DOCTOR LIC | OTHER |