Healthcare Provider Details

I. General information

NPI: 1316012743
Provider Name (Legal Business Name): CARMEN C VIVERO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 08/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PLANTATION ISLAND DR S SUITE 402-B
ST AUGUSTINE FL
32080-3108
US

IV. Provider business mailing address

1301 PLANTATION ISLAND DR S SUITE 402-B
ST AUGUSTINE FL
32080-3108
US

V. Phone/Fax

Practice location:
  • Phone: 904-460-0707
  • Fax: 904-460-0727
Mailing address:
  • Phone: 904-460-0707
  • Fax: 904-460-0727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License NumberME0076599
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: