Provider Demographics
NPI:1972528214
Name:MELENDEZ-RIVERA, IVAN (MD)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:MELENDEZ-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 1:8169 CALLE CONCORDIA STE 412
Mailing Address - Street 2:COND. SAN VICENTE
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00717-1567
Mailing Address - Country:US
Mailing Address - Phone:787-284-5884
Mailing Address - Fax:787-284-5874
Practice Address - Street 1:8169 CALLE CONCORDIA STE 412
Practice Address - Street 2:COND. SAN VICENTE
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717-1567
Practice Address - Country:US
Practice Address - Phone:787-284-5884
Practice Address - Fax:787-284-5874
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2010-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12061207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR200031OtherMMM
PRG56993Medicare UPIN
PR89127Medicare ID - Type Unspecified