Healthcare Provider Details

I. General information

NPI: 1043956741
Provider Name (Legal Business Name): MARCOS ANTONIO RIVERA ROMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2022
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3647 S ORLANDO DR
SANFORD FL
32773-5611
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 407-541-0115
  • Fax: 407-344-7910
Mailing address:
  • Phone: 844-630-0700
  • Fax: 877-374-1924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberACN1503
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: