=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760286983
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSE ALFREDO RIVERA MARTINEZ MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2025
-----------------------------------------------------
Last Update Date | 04/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 141 N 6TH ST
-----------------------------------------------------
City | HAINES CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33844-4207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-353-1538
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3714 NE LAKE SEBRING DR
-----------------------------------------------------
City | SEBRING
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33870-8452
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-406-4425
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 11038650
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------