Provider Demographics
NPI:1396722948
Name:RIVERA, JOSE NELSON JR (MD)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:NELSON
Last Name:RIVERA
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:JOSE
Other - Middle Name:N
Other - Last Name:RIVERA-RUIZ
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 69004
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71306-9004
Mailing Address - Country:US
Mailing Address - Phone:318-466-2760
Mailing Address - Fax:318-466-2760
Practice Address - Street 1:2495 SHREVEPORT HWY # 71N
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-4044
Practice Address - Country:US
Practice Address - Phone:318-466-2760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-26
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13337207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR13337OtherMEDICAL LICENSE