Provider Demographics
NPI:1871923037
Name:POINCIANA MEDICAL CLINIC
Entity type:Organization
Organization Name:POINCIANA MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:RIVERA SOLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-572-8862
Mailing Address - Street 1:51 N DOVERPLUM AVE
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34758-3308
Mailing Address - Country:US
Mailing Address - Phone:407-572-8862
Mailing Address - Fax:407-572-8863
Practice Address - Street 1:51 N DOVERPLUM AVE
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34758-3308
Practice Address - Country:US
Practice Address - Phone:407-572-8862
Practice Address - Fax:407-572-8863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-25
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN241208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001456400Medicaid
FL001456400Medicaid