Provider Demographics
NPI:1104501337
Name:RIVERA, GIOVANNI (OPT)
Entity type:Individual
Prefix:
First Name:GIOVANNI
Middle Name:
Last Name:RIVERA
Suffix:
Gender:M
Credentials:OPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB. LOMAS DE COUNTRY CLUB
Mailing Address - Street 2:U-47 CALLE 17
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00730
Mailing Address - Country:US
Mailing Address - Phone:787-298-0316
Mailing Address - Fax:
Practice Address - Street 1:2020 AVE BORINQUEN
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00915-3822
Practice Address - Country:US
Practice Address - Phone:787-268-4171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-15
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1298156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty