Provider Demographics
NPI:1447644836
Name:DE JESUS RIVERA, MIRIANDRA (MD)
Entity type:Individual
Prefix:
First Name:MIRIANDRA
Middle Name:
Last Name:DE JESUS RIVERA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7901 4TH ST N STE 300
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-4399
Mailing Address - Country:US
Mailing Address - Phone:813-591-4938
Mailing Address - Fax:813-219-8035
Practice Address - Street 1:7901 4TH ST N STE 300
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-4399
Practice Address - Country:US
Practice Address - Phone:813-591-4938
Practice Address - Fax:813-219-8035
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-24
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1374202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry