Provider Demographics
NPI:1275521023
Name:RIVERA, JUAN I (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:I
Last Name:RIVERA
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 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:315 E OLYMPIA AVE
Practice Address - Street 2:#111
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33950-3831
Practice Address - Country:US
Practice Address - Phone:941-205-2600
Practice Address - Fax:941-205-2601
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA046778207Q00000X
FLME050857207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL072052600Medicaid
FL04080OtherFL BC
FL04080ZMedicare PIN
FL04080WMedicare PIN
FL04080OtherFL BC