Provider Demographics
NPI:1215903745
Name:RIVERA BOU, WANDA L (MD)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:L
Last Name:RIVERA BOU
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 596
Mailing Address - Street 2:
Mailing Address - City:LUQUILLO
Mailing Address - State:PR
Mailing Address - Zip Code:00773-0596
Mailing Address - Country:US
Mailing Address - Phone:787-487-2169
Mailing Address - Fax:787-487-2169
Practice Address - Street 1:CARR #3 K.M. 8.3 AVE. 65 INFANTERIA
Practice Address - Street 2:HOSPITAL UPR
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00914
Practice Address - Country:US
Practice Address - Phone:787-757-1800
Practice Address - Fax:787-750-0930
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-24
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12963207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0022467Medicare ID - Type Unspecified
PRI15910Medicare UPIN