Provider Demographics
NPI:1043956741
Name:RIVERA ROMAN, MARCOS ANTONIO (MD)
Entity type:Individual
Prefix:DR
First Name:MARCOS
Middle Name:ANTONIO
Last Name:RIVERA ROMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 W COLONIAL DR STE 303
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-6863
Mailing Address - Country:US
Mailing Address - Phone:321-332-6947
Mailing Address - Fax:407-286-4515
Practice Address - Street 1:1130 S SEMORAN BLVD STE B-C
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32807-1457
Practice Address - Country:US
Practice Address - Phone:407-382-1376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-06
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR22914208D00000X
FLACN1503208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL117196700Medicaid