Provider Demographics
NPI:1184698797
Name:RIESTRA, JOSE LUIS (MD)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:LUIS
Last Name:RIESTRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:Y2 CALLE HASTINGS
Mailing Address - Street 2:GARDEN HILLS
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00966-2832
Mailing Address - Country:US
Mailing Address - Phone:787-781-6889
Mailing Address - Fax:
Practice Address - Street 1:68 CALLE SANTA CRUZ
Practice Address - Street 2:TORRE SAN PABLO, SUITE 904
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961-7031
Practice Address - Country:US
Practice Address - Phone:787-780-5369
Practice Address - Fax:787-780-5527
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PR5936207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRD-08717Medicare UPIN
PR9-7449Medicare ID - Type Unspecified