Provider Demographics
NPI:1073696027
Name:RIVERA, CARMELO (OD)
Entity Type:Individual
Prefix:
First Name:CARMELO
Middle Name:
Last Name:RIVERA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB LA INMACULADA
Mailing Address - Street 2:295 CALLE MONS-BERRIOS
Mailing Address - City:VEGA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00692
Mailing Address - Country:US
Mailing Address - Phone:787-883-0106
Mailing Address - Fax:
Practice Address - Street 1:PLAZA VEGA BAJA
Practice Address - Street 2:
Practice Address - City:VEGA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00693
Practice Address - Country:US
Practice Address - Phone:787-858-6567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR357152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist