Provider Demographics
NPI:1932302502
Name:RIVERA, JORGE R JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:R
Last Name:RIVERA
Suffix:JR
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 1:3638 VERONA TRL
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-4919
Mailing Address - Country:US
Mailing Address - Phone:540-772-2776
Mailing Address - Fax:
Practice Address - Street 1:3638 VERONA TRL
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-4919
Practice Address - Country:US
Practice Address - Phone:540-772-2776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD441893207R00000X
VA0101248583207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1025751630001Medicaid
PA214748Medicare PIN