Healthcare Provider Details

I. General information

NPI: 1326498676
Provider Name (Legal Business Name): CONVIVA SPECIALTY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2016
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12905 SW 42ND ST STE 103
MIAMI FL
33175-2910
US

IV. Provider business mailing address

6101 BLUE LAGOON DR STE 200
MIAMI FL
33126-3168
US

V. Phone/Fax

Practice location:
  • Phone: 786-801-5620
  • Fax:
Mailing address:
  • Phone: 305-500-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME116882
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberME129977
License Number StateFL

VIII. Authorized Official

Name: DR. JESSICA BONETTI
Title or Position: ASSOCIATE DIRECTOR
Credential:
Phone: 305-500-2000