Provider Demographics
NPI:1003893538
Name:RIVERA, JUAN J (DPM)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:J
Last Name:RIVERA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2835 W DE LEON ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-4168
Mailing Address - Country:US
Mailing Address - Phone:813-254-6592
Mailing Address - Fax:813-254-3634
Practice Address - Street 1:2835 W DE LEON ST
Practice Address - Street 2:SUITE 101
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-4168
Practice Address - Country:US
Practice Address - Phone:813-254-6592
Practice Address - Fax:813-254-3634
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPO2416213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2700454OtherUNITED HEALTHCARE
FL65329OtherBLUE CROSS BLUE SHIELD
FL480018728Medicare PIN
FL65329OtherBLUE CROSS BLUE SHIELD
FLU48151Medicare UPIN