Healthcare Provider Details

I. General information

NPI: 1851672372
Provider Name (Legal Business Name): JUDY STOVALL RIVENBARK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2011
Last Update Date: 08/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 STOCKTON STREET
JACKSONVILLE FL
32204
US

IV. Provider business mailing address

POST OFFICE BOX 15580
FERNANDIDA BEACH FL
32035
US

V. Phone/Fax

Practice location:
  • Phone: 800-888-8776
  • Fax:
Mailing address:
  • Phone: 800-888-8776
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberME81633
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: