Provider Demographics
NPI:1215029046
Name:RIVERA CRUZ, GUSTAVO (MD)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:RIVERA CRUZ
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:PO BOX 20000 PMB 563
Mailing Address - Street 2:
Mailing Address - City:CANOVANAS
Mailing Address - State:PR
Mailing Address - Zip Code:00729
Mailing Address - Country:US
Mailing Address - Phone:787-768-7900
Mailing Address - Fax:787-768-7900
Practice Address - Street 1:LAGUNA GARDENS SHOPPING CENTER
Practice Address - Street 2:SUITE 211
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00979
Practice Address - Country:US
Practice Address - Phone:787-791-8897
Practice Address - Fax:787-791-8801
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR137642084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
222151OtherPREFERRED HEALTH
84357OtherSSS
9658OtherINTERNATIONAL MED CARD
411255024OtherPROSAM
2602997OtherACAA
1763OtherMMM
1937OtherHUMANA VIA APS
84357OtherSSS OPTIMO
PQ1051OtherPALIC
1937OtherHUMANA VIA APS
222151OtherPREFERRED HEALTH