Basic Information
| Provider Information | |||||||||
| NPI: | 1467897975 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VIVAR | ||||||||
| FirstName: | SUSSI | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11513 LAKE UNDERHILL RD | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328255001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072491234 | ||||||||
| FaxNumber: | 4072491755 | ||||||||
| Practice Location | |||||||||
| Address1: | 1651 N SEMORAN BLVD | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328073575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072491234 | ||||||||
| FaxNumber: | 4072491755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2013 | ||||||||
| LastUpdateDate: | 10/26/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME128202 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 017692800 | 05 | FL | MEDICAID |