MEDICARE: TEDDY J DORIVAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PACN140	FL
2	363AM0700X	Medical Physician Assistant	001732-P.A.	PR
3	363AM0700X	Medical Physician Assistant	10019	AZ

General Provider Information

NPI Number	:	1417636549
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TEDDY J DORIVAL

Provider Business Mailing Address
First Line	:	12600 NW 19TH AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33167-2159
Country	:	US
Telephone Number	:	305-842-0171
Fax Number	:

Provider Business Practice Location Address
First Line	:	12600 NW 19TH AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33167-2159
Country	:	US
Telephone Number	:	305-842-0171
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2023
Last Update Date	:	03/06/2026

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Directions to “ TEDDY J DORIVAL ” Practice Location

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