Provider Demographics
NPI:1275663643
Name:RIVERA, TEODORO (BSPH)
Entity type:Individual
Prefix:MR
First Name:TEODORO
Middle Name:
Last Name:RIVERA
Suffix:
Gender:M
Credentials:BSPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 CALLE E BETANCES
Mailing Address - Street 2:
Mailing Address - City:VEGA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00693-4463
Mailing Address - Country:US
Mailing Address - Phone:787-858-2784
Mailing Address - Fax:787-858-2784
Practice Address - Street 1:4 CALLE E BETANCES
Practice Address - Street 2:
Practice Address - City:VEGA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00693-4463
Practice Address - Country:US
Practice Address - Phone:787-858-2784
Practice Address - Fax:787-858-2784
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2512183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR4662700001Medicare ID - Type UnspecifiedPROVIDER