Provider Demographics
NPI:1689998643
Name:MEDICAL X RAY CENTER PONCE
Entity Type:Organization
Organization Name:MEDICAL X RAY CENTER PONCE
Other - Org Name:JOSE A. RIVERA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:A
Authorized Official - Last Name:RIVERA RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-615-3318
Mailing Address - Street 1:PO BOX 10189
Mailing Address - Street 2:
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00732-0189
Mailing Address - Country:US
Mailing Address - Phone:787-840-5090
Mailing Address - Fax:787-840-5090
Practice Address - Street 1:509 AVE TITO CASTRO
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716-0207
Practice Address - Country:US
Practice Address - Phone:787-840-5090
Practice Address - Fax:787-840-5090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-19
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRG06610Medicare UPIN