Provider Demographics
NPI:1215423645
Name:FUENTES RIVERA, LYDIA LIZ (MD)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:LIZ
Last Name:FUENTES RIVERA
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 1:7842 73RD PL
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11385-7426
Mailing Address - Country:US
Mailing Address - Phone:787-363-6914
Mailing Address - Fax:
Practice Address - Street 1:8268 164TH ST BLDG 7TH
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-1121
Practice Address - Country:US
Practice Address - Phone:718-883-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR22193207R00000X, 208D00000X
FL157982207RN0300X
PR34120390200000X
PR33454390200000X
PR35007390200000X
NY325936207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program