Provider Demographics
NPI:1124554449
Name:RIVERA NAZARIO, IVAN AUGUSTO (MD)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:AUGUSTO
Last Name:RIVERA NAZARIO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 191811
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00919-1811
Mailing Address - Country:US
Mailing Address - Phone:787-763-4149
Mailing Address - Fax:
Practice Address - Street 1:150 AVE AMERICO MIRANDA BO MONASILLO
Practice Address - Street 2:AREA DE CENTRO MEDICO METROPOLITANO
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00935-0001
Practice Address - Country:US
Practice Address - Phone:787-763-4149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-05
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR21051207R00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty