Provider Demographics
NPI:1760846497
Name:PAGAN RIVERA, BRYAN LESLIE (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:LESLIE
Last Name:PAGAN 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:PO BOX 1642
Mailing Address - Street 2:
Mailing Address - City:SAN GERMAN
Mailing Address - State:PR
Mailing Address - Zip Code:00683-1642
Mailing Address - Country:US
Mailing Address - Phone:787-379-2110
Mailing Address - Fax:
Practice Address - Street 1:1050 AVE LOS CORAZONES STE 2
Practice Address - Street 2:
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680-7041
Practice Address - Country:US
Practice Address - Phone:787-265-5334
Practice Address - Fax:787-833-6640
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-08
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR19262207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR19262OtherMEDICAL LICENSE