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General NPI Number Information
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NPI Number | 1538157862
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Entity Type | Individual
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Provider Name | VIVIAN VIRELLA MD
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Gender | Female
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Dates
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Enumeration Date | 10/11/2005
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Last Update Date | 11/09/2020
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Provider Practice Location Address
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Address Line | 5245 US HIGHWAY 98 N
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City | LAKELAND
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State | FL
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Zip | 33809-0516
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Country | US
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Telephone | 863-644-3585
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Fax | 863-644-3171
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Provider Business Mailing Address
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Address Line | 5425 S FLORIDA AVE
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City | LAKELAND
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State | FL
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Zip | 33813-2523
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Country | US
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Telephone | 863-644-3585
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Fax | 863-644-3171
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 15253
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License Number State | PR
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