Provider Demographics
NPI:1346979796
Name:RODRIGUEZ RIVERA, ALEXIS (MD)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:RODRIGUEZ 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:HC 2 BOX 3929
Mailing Address - Street 2:
Mailing Address - City:LUQUILLO
Mailing Address - State:PR
Mailing Address - Zip Code:00773-9821
Mailing Address - Country:US
Mailing Address - Phone:787-406-8039
Mailing Address - Fax:
Practice Address - Street 1:CALLE 6 #241 PARCELAS FORTUNAS
Practice Address - Street 2:
Practice Address - City:LUQUILLO
Practice Address - State:PR
Practice Address - Zip Code:00773
Practice Address - Country:US
Practice Address - Phone:787-406-8039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-09
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR100507993103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR6126437OtherPRIVATE
PR6126437Medicaid