Provider Demographics
NPI:1154636462
Name:RIVERA COLON, GLORIMAR (MD)
Entity Type:Individual
Prefix:
First Name:GLORIMAR
Middle Name:
Last Name:RIVERA COLON
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 1:5415 MAPLE AVE APT 429
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-7405
Mailing Address - Country:US
Mailing Address - Phone:787-344-6855
Mailing Address - Fax:
Practice Address - Street 1:5415 MAPLE AVE APT 429
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7405
Practice Address - Country:US
Practice Address - Phone:787-344-6855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-11
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12672I390200000X
TXQ6363174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program