Provider Demographics
NPI:1780664177
Name:RIVERA, LUIS R (MD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:R
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 1:8600 NW 41ST ST
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166-6202
Mailing Address - Country:US
Mailing Address - Phone:305-642-5366
Mailing Address - Fax:305-631-3828
Practice Address - Street 1:11501 SW 40TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-3313
Practice Address - Country:US
Practice Address - Phone:305-642-5366
Practice Address - Fax:305-631-3828
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG0526208800000X
FLME109084208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX117315502Medicaid
TXC76498Medicare UPIN
TX117315502Medicaid