Provider Demographics
NPI:1316908007
Name:RIVERA, KENNETH (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:RIVERA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9163 CALLE MARINA
Mailing Address - Street 2:ESTANCIAS DE ARAGON APT 403B
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00717-2006
Mailing Address - Country:US
Mailing Address - Phone:787-284-0737
Mailing Address - Fax:
Practice Address - Street 1:9163 CALLE MARINA
Practice Address - Street 2:ESTANCIAS DE ARAGON APT 403B
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717-2006
Practice Address - Country:US
Practice Address - Phone:787-284-0737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12788174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR12788OtherMEDICAL LICENSE