Provider Demographics
NPI:1285283317
Name:RIVERA, ROBERT (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:RIVERA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ROBERT
Other - Middle Name:WILSON
Other - Last Name:RIVERA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MT
Mailing Address - Street 1:P.O. BOX 459
Mailing Address - Street 2:
Mailing Address - City:CIDRA
Mailing Address - State:PR
Mailing Address - Zip Code:00739
Mailing Address - Country:US
Mailing Address - Phone:787-520-7390
Mailing Address - Fax:787-520-7108
Practice Address - Street 1:CARR. PR 173, KM 6, HM5, SECTOR SAN JOSE, BO. RABANAL
Practice Address - Street 2:
Practice Address - City:CIDRA
Practice Address - State:PR
Practice Address - Zip Code:00739
Practice Address - Country:US
Practice Address - Phone:787-520-7390
Practice Address - Fax:787-520-7108
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR9611247ZC0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1417038969Medicaid