Provider Demographics
NPI:1295821031
Name:RIVERA, MODESTO SANTOS (MD)
Entity Type:Individual
Prefix:DR
First Name:MODESTO
Middle Name:SANTOS
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 1:806 SOLOMONS ISLAND ROAD NORTH
Mailing Address - Street 2:
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678
Mailing Address - Country:US
Mailing Address - Phone:410-535-4242
Mailing Address - Fax:410-535-4983
Practice Address - Street 1:806 SOLOMONS ISLAND RD.
Practice Address - Street 2:
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678
Practice Address - Country:US
Practice Address - Phone:410-535-4242
Practice Address - Fax:410-535-4983
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD19963174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0283OtherGHMSI
2122218OtherMAMSI
7089Medicare ID - Type Unspecified
2122218OtherMAMSI