Provider Demographics
NPI:1649426255
Name:ROVIRA, WILDALIS (MD)
Entity type:Individual
Prefix:
First Name:WILDALIS
Middle Name:
Last Name:ROVIRA
Suffix:
Gender:F
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 601
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00681-0601
Mailing Address - Country:US
Mailing Address - Phone:787-439-7259
Mailing Address - Fax:787-265-5951
Practice Address - Street 1:#15 DR. BASORA ST.
Practice Address - Street 2:HOSPITAL PEREA
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680
Practice Address - Country:US
Practice Address - Phone:787-834-0101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-14
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR17176208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice