Provider Demographics
NPI:1407982812
Name:RIVERA, WANDA I (OD)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:I
Last Name:RIVERA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 AVE ESMERALDA
Mailing Address - Street 2:URB PONCE DE LEON
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00969-4429
Mailing Address - Country:US
Mailing Address - Phone:787-790-3848
Mailing Address - Fax:
Practice Address - Street 1:59 AVE ESMERALDA
Practice Address - Street 2:URB PONCE DE LEON
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00969-4429
Practice Address - Country:US
Practice Address - Phone:787-790-3848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR522152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR100944OtherOPTOMETRY
PR50553OtherOPTOMETRY
PR58260OtherOPTOMETRY
PR215953OtherOPTOMETRY
PR0058260Medicare ID - Type UnspecifiedOPTOMETRY
PRV-06280Medicare UPIN