Provider Demographics
NPI:1336378074
Name:RIVERA, ANTONIO ALBERTO
Entity Type:Individual
Prefix:MRS
First Name:ANTONIO
Middle Name:ALBERTO
Last Name:RIVERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CARR 152 SECTOR PEPE MORALES BO. ANONES
Mailing Address - Street 2:
Mailing Address - City:NARANJITO
Mailing Address - State:PR
Mailing Address - Zip Code:00719
Mailing Address - Country:US
Mailing Address - Phone:787-361-9767
Mailing Address - Fax:787-785-6810
Practice Address - Street 1:AVE. MINILLAS CARR 631 KM.2..3 CONDOMINIO BAYAMONTE
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00956
Practice Address - Country:US
Practice Address - Phone:787-361-9767
Practice Address - Fax:787-785-6810
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-02
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR186406332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR120786Medicare UPIN