Basic Information
| Provider Information | |||||||||
| NPI: | 1679557912 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DELTORO RIVERA | ||||||||
| FirstName: | NYDIA | ||||||||
| MiddleName: | GRICELLE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD, WCC. DWC, CWS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12171 SW 268TH ST | ||||||||
| Address2: | |||||||||
| City: | HOMESTEAD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330328001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052780200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1120 CARLTON AVE | ||||||||
| Address2: | |||||||||
| City: | LAKE WALES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338534348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632704546 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2005 | ||||||||
| LastUpdateDate: | 03/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 13203 | PR | N | Allopathic & Osteopathic Physicians | General Practice | 208D00000X | ACN634 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.