Healthcare Provider Details

I. General information

NPI: 1619662343
Provider Name (Legal Business Name): DOUGLAS MANUEL ERNESTO RIVERA AGOSTO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9330 US 301 S
RIVERVIEW FL
33578-6300
US

IV. Provider business mailing address

2020 59TH ST W
BRADENTON FL
34209-4604
US

V. Phone/Fax

Practice location:
  • Phone: 813-471-0000
  • Fax:
Mailing address:
  • Phone: 941-792-6611
  • Fax:

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 State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME181089
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: