Provider Demographics
NPI:1972064103
Name:RIVERA AGUASVIVAS, LUIS RAFAEL (MD)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:RAFAEL
Last Name:RIVERA AGUASVIVAS
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 1:1611 NW 12 AVENUE
Mailing Address - Street 2:HOLTZ BUILDING, EAST TOWER 2169
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136
Mailing Address - Country:US
Mailing Address - Phone:305-585-1280
Mailing Address - Fax:
Practice Address - Street 1:1611 NW 12 AVENUE
Practice Address - Street 2:HOLTZ BUILDING, EAST TOWER 2169
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136
Practice Address - Country:US
Practice Address - Phone:305-585-1280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-29
Last Update Date:2019-11-18
Deactivation Date:2019-11-04
Deactivation Code:
Reactivation Date:2019-11-18
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLTRN29803390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program