MEDICARE: DR. MICHELLE LIZARDI RIVERA O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OEG003127	PA

General Provider Information

NPI Number	:	1043434533
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHELLE LIZARDI RIVERA O.D.

Provider Business Mailing Address
First Line	:	1412 FAIRMOUNT AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19130-2908
Country	:	US
Telephone Number	:	904-296-0098
Fax Number	:

Provider Business Practice Location Address
First Line	:	7205 BONNEVAL RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-7565
Country	:	US
Telephone Number	:	904-296-0098
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/13/2007
Last Update Date	:	01/17/2017

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