Healthcare Provider Details

I. General information

NPI: 1033551163
Provider Name (Legal Business Name): ALEJANDRA CAROLINA VIVAS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2013
Last Update Date: 11/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1951 SW 172ND AVE 416
MIRAMAR FL
33029-5593
US

IV. Provider business mailing address

151 SOUTHHALL LN STE 300
MAITLAND FL
32751-7172
US

V. Phone/Fax

Practice location:
  • Phone: 954-447-3200
  • Fax: 954-447-3205
Mailing address:
  • Phone: 407-875-2080
  • Fax: 407-650-3455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME128624
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: