Provider Demographics
NPI:1821052291
Name:RIVERA, MARCO A (MD)
Entity Type:Individual
Prefix:
First Name:MARCO
Middle Name:A
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 1:1051 CALLE 3 SE
Mailing Address - Street 2:MEDICAL CENTER PLAZA 610, LA RIVIERA
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00921-3000
Mailing Address - Country:US
Mailing Address - Phone:787-775-2412
Mailing Address - Fax:787-781-1110
Practice Address - Street 1:1051 CALLE 3 SE
Practice Address - Street 2:MEDICAL CENTER PLAZA 610, LA RIVIERA
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00921-3000
Practice Address - Country:US
Practice Address - Phone:787-775-2412
Practice Address - Fax:787-781-1110
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6683174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist