Provider Demographics
NPI:1568510709
Name:RIVERA, JORGE M (DPM)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:M
Last Name:RIVERA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16909 N BAY RD APT 715
Mailing Address - Street 2:
Mailing Address - City:SUNNY ISLES BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33160-4226
Mailing Address - Country:US
Mailing Address - Phone:305-528-8328
Mailing Address - Fax:
Practice Address - Street 1:17901 NW 5TH ST STE 106
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-2810
Practice Address - Country:US
Practice Address - Phone:954-704-2888
Practice Address - Fax:954-704-0227
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO 3219213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery