Provider Demographics
NPI:1679686919
Name:RIVAS DIAZ, LOURDES (MD)
Entity Type:Individual
Prefix:
First Name:LOURDES
Middle Name:
Last Name:RIVAS DIAZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:977 CALLE GRAN CAPITAN
Mailing Address - Street 2:PALACIO DE MARBELLA
Mailing Address - City:TOA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00953-5205
Mailing Address - Country:US
Mailing Address - Phone:787-163-1332
Mailing Address - Fax:
Practice Address - Street 1:CARR 152 KM 12 HM 2, NARANJITO BARRANQUITAS
Practice Address - Street 2:
Practice Address - City:NARANJITO
Practice Address - State:PR
Practice Address - Zip Code:00719
Practice Address - Country:US
Practice Address - Phone:787-869-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12209208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRH51545Medicare UPIN