Healthcare Provider Details

I. General information

NPI: 1477968667
Provider Name (Legal Business Name): MARY DIANA VIVIRITO O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2014
Last Update Date: 09/15/2024
Certification Date: 09/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 N IMPERIAL AVE
EL CENTRO CA
92243-1916
US

IV. Provider business mailing address

812 N IMPERIAL AVE
EL CENTRO CA
92243-1916
US

V. Phone/Fax

Practice location:
  • Phone: 760-352-7460
  • Fax: 888-210-5799
Mailing address:
  • Phone: 760-352-7460
  • Fax: 888-210-5799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0003100
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number33798TLG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: