MEDICARE: DR. VIVIAN VIRELLA MD

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	208D00000X	General Practice Physician	15253	PR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	15253	OTHER	PR	LIC.
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538157862
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VIVIAN VIRELLA MD

Provider Business Mailing Address
First Line	:	5425 S FLORIDA AVE
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33813-2523
Country	:	US
Telephone Number	:	863-644-3585
Fax Number	:	863-644-3171

Provider Business Practice Location Address
First Line	:	5245 US HIGHWAY 98 N
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33809-0516
Country	:	US
Telephone Number	:	863-644-3585
Fax Number	:	863-644-3171

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

Provider Enumeration Date	:	10/11/2005
Last Update Date	:	11/09/2020

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