Provider Demographics
NPI:1538228812
Name:RIVERA, JORGE (MD)
Entity type:Individual
Prefix:DR
First Name:JORGE
Middle Name:
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:TIERRA DEL SOL
Mailing Address - Street 2:EDIF. G 232
Mailing Address - City:HUMACAO
Mailing Address - State:PR
Mailing Address - Zip Code:00791
Mailing Address - Country:US
Mailing Address - Phone:787-656-2424
Mailing Address - Fax:787-656-2444
Practice Address - Street 1:AVE. FONT MARTELO #3
Practice Address - Street 2:HOSPITAL HIMA HUMACAO
Practice Address - City:HUMACAO
Practice Address - State:PR
Practice Address - Zip Code:00791
Practice Address - Country:US
Practice Address - Phone:787-656-2424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11541208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR11541OtherLICENSE OF PR
PR11541OtherLICENSE OF PR