Provider Demographics
NPI:1780682047
Name:RIVERA, JUAN R (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
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 1:500 E CENTRAL AVE
Mailing Address - Street 2:BOND CLINIC, P.A.
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-3053
Mailing Address - Country:US
Mailing Address - Phone:863-293-1191
Mailing Address - Fax:
Practice Address - Street 1:500 E CENTRAL AVE
Practice Address - Street 2:BOND CLINIC, P.A.
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-3053
Practice Address - Country:US
Practice Address - Phone:863-293-1191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME-82507207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL26220341-00Medicaid
FLH55041Medicare UPIN
FL26220341-00Medicaid