Provider Demographics
NPI:1083350623
Name:RIVERA FUENTES, BRENDA LUZ (MD)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:LUZ
Last Name:RIVERA FUENTES
Suffix:
Gender:F
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 925
Mailing Address - Street 2:
Mailing Address - City:DORADO
Mailing Address - State:PR
Mailing Address - Zip Code:00646-0925
Mailing Address - Country:US
Mailing Address - Phone:787-250-0084
Mailing Address - Fax:
Practice Address - Street 1:100 CARR 165 TORRE 1 SUITE 303
Practice Address - Street 2:
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00968
Practice Address - Country:US
Practice Address - Phone:787-277-0847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-06
Last Update Date:2024-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1270-PA363A00000X
PR24148208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant