Basic Information
| Provider Information | |||||||||
| NPI: | 1639366909 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CEO/CENTER FOR EXECUTIVE OPHTHALMOLOOGY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CEO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 566120 | ||||||||
| Address2: | |||||||||
| City: | PINECREST | ||||||||
| State: | FL | ||||||||
| PostalCode: | 332566120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056662365 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1661 SW 37TH AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331451754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3054612400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2007 | ||||||||
| LastUpdateDate: | 10/01/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RIVERA | ||||||||
| AuthorizedOfficialFirstName: | ALFRED | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3056662365 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | ME44196 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.