Provider Demographics
NPI:1376608984
Name:RIVERA, LUIS A (MD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:A
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:PMB 232 PO BOX 7891
Mailing Address - Street 2:
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00970
Mailing Address - Country:US
Mailing Address - Phone:787-273-1946
Mailing Address - Fax:787-782-4615
Practice Address - Street 1:CARR.21S-3 NUM.2 LAS LOMAS
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00921
Practice Address - Country:US
Practice Address - Phone:787-273-1946
Practice Address - Fax:787-782-4615
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5686174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0026313Medicare ID - Type UnspecifiedMEDICARE
PRD08365Medicare UPIN