Provider Demographics
NPI:1740264712
Name:RIVERA RIVERA, ILDEFONSO (MD)
Entity type:Individual
Prefix:DR
First Name:ILDEFONSO
Middle Name:
Last Name:RIVERA 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:PO BOX 3018
Mailing Address - Street 2:
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00960-3018
Mailing Address - Country:US
Mailing Address - Phone:787-787-0210
Mailing Address - Fax:787-269-5575
Practice Address - Street 1:URB SANTA CRUZ #68
Practice Address - Street 2:SUITE 506 TORRE SAN PABLO
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00959
Practice Address - Country:US
Practice Address - Phone:787-786-4913
Practice Address - Fax:787-269-5575
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-02
Last Update Date:2019-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6051207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR26591Medicare ID - Type Unspecified
PRE10298Medicare UPIN