Provider Demographics
NPI:1194142521
Name:DRA. JUDIBELLE RIVERA DE JESUS MD, PSC
Entity type:Organization
Organization Name:DRA. JUDIBELLE RIVERA DE JESUS MD, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUDIBELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-825-2420
Mailing Address - Street 1:41 CALLE TIBES
Mailing Address - Street 2:MANSIONES DEL SUR
Mailing Address - City:COTO LAUREL
Mailing Address - State:PR
Mailing Address - Zip Code:00780-2092
Mailing Address - Country:US
Mailing Address - Phone:787-825-2420
Mailing Address - Fax:787-825-2565
Practice Address - Street 1:33 CALLE BALDORIOTY
Practice Address - Street 2:
Practice Address - City:COAMO
Practice Address - State:PR
Practice Address - Zip Code:00769-3122
Practice Address - Country:US
Practice Address - Phone:787-825-2420
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-24
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12140261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR88806Medicare PIN