Provider Demographics
NPI:1528049921
Name:RIVERA, MARVIN (OD)
Entity type:Individual
Prefix:MR
First Name:MARVIN
Middle Name:
Last Name:RIVERA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 58 BOX 13692
Mailing Address - Street 2:
Mailing Address - City:AGUADA
Mailing Address - State:PR
Mailing Address - Zip Code:00602-9724
Mailing Address - Country:US
Mailing Address - Phone:787-252-9557
Mailing Address - Fax:
Practice Address - Street 1:975 AVE DE HOSTOS
Practice Address - Street 2:STE 255
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680-1255
Practice Address - Country:US
Practice Address - Phone:787-834-3320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR318152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR58114Medicare ID - Type Unspecified