Provider Demographics
NPI:1306890157
Name:RIVERA, EDGARDO
Entity type:Individual
Prefix:
First Name:EDGARDO
Middle Name:
Last Name:RIVERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB VILLA LISSETTE
Mailing Address - Street 2:B 9 CALLE BENITEZ
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00969
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:ASHFORD MEDICAL CTR
Practice Address - Street 2:SUITE 402
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00907-1510
Practice Address - Country:US
Practice Address - Phone:787-724-8441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12180207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
0089281Medicare ID - Type Unspecified
H94765Medicare UPIN