Provider Demographics
NPI:1649376997
Name:BADILLO RIVERA, JEANNINE M (MD)
Entity type:Individual
Prefix:
First Name:JEANNINE
Middle Name:M
Last Name:BADILLO RIVERA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PMB 358 667 PONCE DE LEON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00907-3201
Mailing Address - Country:US
Mailing Address - Phone:787-263-0644
Mailing Address - Fax:787-535-1024
Practice Address - Street 1:BO JAUCA 11 PLAZA OASIS
Practice Address - Street 2:CARR 153 KM 6-9
Practice Address - City:SANTA ISABEL
Practice Address - State:PR
Practice Address - Zip Code:00757
Practice Address - Country:US
Practice Address - Phone:787-263-0644
Practice Address - Fax:787-535-1024
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR120862085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G41336Medicare UPIN
PRG41336Medicare ID - Type Unspecified