Provider Demographics
NPI:1487940573
Name:RIVERA-NIEVES, DESIREE (MD)
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:
Last Name:RIVERA-NIEVES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 58TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33714-1326
Mailing Address - Country:US
Mailing Address - Phone:727-895-3702
Mailing Address - Fax:727-896-3828
Practice Address - Street 1:4040 SAWYER RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233-1272
Practice Address - Country:US
Practice Address - Phone:941-960-1314
Practice Address - Fax:941-960-1394
Is Sole Proprietor?:No
Enumeration Date:2011-06-27
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1343862080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100065000Medicaid