Provider Demographics
NPI:1104105725
Name:J RIVERA ROSALES MD INTERNAL MEDICINE PROFESSIONAL ASSOCIATION
Entity type:Organization
Organization Name:J RIVERA ROSALES MD INTERNAL MEDICINE PROFESSIONAL ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JULIO
Authorized Official - Middle Name:R
Authorized Official - Last Name:RIVERA ROSALES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-305-0725
Mailing Address - Street 1:PO BOX 132184
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77393-2184
Mailing Address - Country:US
Mailing Address - Phone:281-305-0725
Mailing Address - Fax:281-465-9992
Practice Address - Street 1:1111 MEDICAL PLAZA DR
Practice Address - Street 2:SUITE 190
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77380-3476
Practice Address - Country:US
Practice Address - Phone:281-305-0725
Practice Address - Fax:281-465-9992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-13
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX288184901Medicaid
TXTXB140808Medicare PIN