Provider Demographics
NPI:1144222431
Name:TUNGOL, JOSE RIVERA (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:RIVERA
Last Name:TUNGOL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181 ACADEMY ST
Mailing Address - Street 2:STE 5
Mailing Address - City:PRESQUE ISLE
Mailing Address - State:ME
Mailing Address - Zip Code:04769
Mailing Address - Country:US
Mailing Address - Phone:207-764-0175
Mailing Address - Fax:207-764-7157
Practice Address - Street 1:181 ACADEMY ST
Practice Address - Street 2:STE 5
Practice Address - City:PRESQUE ISLE
Practice Address - State:ME
Practice Address - Zip Code:04769
Practice Address - Country:US
Practice Address - Phone:207-764-0175
Practice Address - Fax:207-764-7157
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-01
Last Update Date:2007-07-08
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-04-03
Provider Licenses
StateLicense IDTaxonomies
ME010870174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEB86308Medicare UPIN
MEMM0317Medicare ID - Type Unspecified