Provider Demographics
NPI:1538148127
Name:RIVERA, JESUS RENE (MD)
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:RENE
Last Name:RIVERA
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:PO BOX 848508
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33084-0508
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1613 HARRISON PKWY
Practice Address - Street 2:#200
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-2853
Practice Address - Country:US
Practice Address - Phone:954-838-2371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME65364207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL379220000Medicaid
FL23761OtherBCBS
FL23761PMedicare ID - Type Unspecified
FL379220000Medicaid
FL23761QMedicare ID - Type Unspecified