MEDICARE: POINCIANA MEDICAL CLINIC

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	208D00000X	General Practice Physician	ACN241	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871923037
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POINCIANA MEDICAL CLINIC

Provider Business Mailing Address
First Line	:	51 N DOVERPLUM AVE
Second Line	:
City	:	KISSIMMEE
State	:	FL
Zip	:	34758-3308
Country	:	US
Telephone Number	:	407-572-8862
Fax Number	:	407-572-8863

Provider Business Practice Location Address
First Line	:	51 N DOVERPLUM AVE
Second Line	:
City	:	KISSIMMEE
State	:	FL
Zip	:	34758-3308
Country	:	US
Telephone Number	:	407-572-8862
Fax Number	:	407-572-8863

Authorized Official
Title or Position	:	MD
Name	:	IVAN A RIVERA SOLER
Credential	:	MD
Telephone Number	:	407-572-8862

Provider Enumeration Date	:	11/25/2013
Last Update Date	:	07/21/2014

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Directions to “POINCIANA MEDICAL CLINIC ” Practice Location

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