Provider Demographics
NPI:1184830879
Name:RIVERA, PEDRO LUIS (MD)
Entity Type:Individual
Prefix:DR
First Name:PEDRO
Middle Name:LUIS
Last Name:RIVERA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:PROF
Other - First Name:PEDRO
Other - Middle Name:LUIS
Other - Last Name:RIVERA MIRANDA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:209 SAVANNAH REAL
Mailing Address - Street 2:
Mailing Address - City:SAN LORENZO
Mailing Address - State:PR
Mailing Address - Zip Code:00754
Mailing Address - Country:US
Mailing Address - Phone:787-344-1808
Mailing Address - Fax:
Practice Address - Street 1:AVE MUNOZ RIVERA 1SR FLOORBLD. DARLINGTON
Practice Address - Street 2:
Practice Address - City:RIO PIEDRAS
Practice Address - State:PR
Practice Address - Zip Code:00925
Practice Address - Country:US
Practice Address - Phone:787-344-1808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR9570208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRF47593Medicare UPIN
PR8-3006Medicare PIN