Provider Demographics
NPI:1962812115
Name:JIMENEZ RIVERA, MAYRA (MD)
Entity type:Individual
Prefix:
First Name:MAYRA
Middle Name:
Last Name:JIMENEZ RIVERA
Suffix:
Gender:F
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:STATE RD 877 KM 1.6 CAM LAS LOMAS CAPUCCINO
Mailing Address - Street 2:
Mailing Address - City:RIO PIEDRAS
Mailing Address - State:PR
Mailing Address - Zip Code:00926
Mailing Address - Country:US
Mailing Address - Phone:787-625-2900
Mailing Address - Fax:
Practice Address - Street 1:STATE RD 877 KM 1.6 CAM LAS LOMAS CAPUCCINO
Practice Address - Street 2:
Practice Address - City:RIO PIEDRAS
Practice Address - State:PR
Practice Address - Zip Code:00926
Practice Address - Country:US
Practice Address - Phone:787-625-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-28
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR21594208D00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program