Provider Demographics
NPI:1891753539
Name:RIVERA, JORNEL (DO)
Entity Type:Individual
Prefix:
First Name:JORNEL
Middle Name:
Last Name:RIVERA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4750 HEMPSTEAD STATION DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5164
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:937-619-4231
Practice Address - Street 1:550 MIRABEAU ST
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:OH
Practice Address - Zip Code:45123-1617
Practice Address - Country:US
Practice Address - Phone:937-981-2116
Practice Address - Fax:937-981-9238
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34006086R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000319617OtherBCBS
OH0119615Medicaid
F92878Medicare UPIN
RI0888102Medicare UPIN