Provider Demographics
NPI:1023021581
Name:DE JESUS RIVERA, CARMEN C (MD)
Entity Type:Individual
Prefix:DR
First Name:CARMEN
Middle Name:C
Last Name:DE JESUS RIVERA
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 1:444 CALLE REY LUIS
Mailing Address - Street 2:LA VILLA DE TORRIMAR
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00969-3170
Mailing Address - Country:US
Mailing Address - Phone:787-782-3870
Mailing Address - Fax:787-708-1354
Practice Address - Street 1:765 AVE SAN PATRICIO
Practice Address - Street 2:URB. LAS LOMAS
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00921-1302
Practice Address - Country:US
Practice Address - Phone:787-782-3870
Practice Address - Fax:787-708-1354
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6955174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR6955OtherSTATE LICENCE NUMBER
PR6163DM0OtherSTATE NARCOTIC LICENCE