Healthcare Provider Details

I. General information

NPI: 1164884540
Provider Name (Legal Business Name): SEBASTIAN RIVERA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2016
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 W CRYSTAL LAKE ST STE 200
ORLANDO FL
32806-4476
US

IV. Provider business mailing address

25 W CRYSTAL LAKE ST STE 200
ORLANDO FL
32806-4476
US

V. Phone/Fax

Practice location:
  • Phone: 407-254-2500
  • Fax: 407-423-2789
Mailing address:
  • Phone: 407-254-2500
  • Fax: 407-423-2789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number54689
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number54689
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberME154646
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: