Provider Demographics
NPI:1679557912
Name:DELTORO RIVERA, NYDIA GRICELLE (MD, WCC DWC, CWS)
Entity type:Individual
Prefix:DR
First Name:NYDIA
Middle Name:GRICELLE
Last Name:DELTORO RIVERA
Suffix:
Gender:F
Credentials:MD, WCC DWC, CWS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12171 SW 268TH ST
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-8001
Mailing Address - Country:US
Mailing Address - Phone:305-278-0200
Mailing Address - Fax:
Practice Address - Street 1:1120 CARLTON AVE
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4348
Practice Address - Country:US
Practice Address - Phone:863-270-4546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13203208D00000X
FLACN634208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIG000ZMedicare PIN
PRH98082Medicare ID - Type Unspecified
PRH98082Medicare PIN