Provider Demographics
NPI:1588800379
Name:RIVERA, JOSE DANIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:DANIEL
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 1:4710 GRAND BEND DR
Mailing Address - Street 2:
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-3683
Mailing Address - Country:US
Mailing Address - Phone:410-247-6773
Mailing Address - Fax:
Practice Address - Street 1:1635 N GEORGE MASON DR
Practice Address - Street 2:SUITE 480
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22205-3601
Practice Address - Country:US
Practice Address - Phone:703-522-7444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-28
Last Update Date:2008-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101050936208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC 87830Medicare PIN
VA129346Medicare PIN