Provider Demographics
NPI:1033317656
Name:RIVERA ALICEA, GRISELL (MD)
Entity Type:Individual
Prefix:
First Name:GRISELL
Middle Name:
Last Name:RIVERA ALICEA
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 1:2225 PONCE BY PASS EDIF PARRAS
Mailing Address - Street 2:STE 105
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00717-1320
Mailing Address - Country:US
Mailing Address - Phone:787-259-1230
Mailing Address - Fax:787-259-1585
Practice Address - Street 1:EDIF PARRAS
Practice Address - Street 2:STE 105
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717-1321
Practice Address - Country:US
Practice Address - Phone:787-259-1230
Practice Address - Fax:787-259-1585
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-05
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11615208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR11615OtherMEDICAL LICENSE