Provider Demographics
NPI:1972576049
Name:RIVERA MARTINEZ, EDGAR (MD)
Entity type:Individual
Prefix:
First Name:EDGAR
Middle Name:
Last Name:RIVERA MARTINEZ
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:PO BOX 2300
Mailing Address - Street 2:PMB 21
Mailing Address - City:AIBONITO
Mailing Address - State:PR
Mailing Address - Zip Code:00705-2300
Mailing Address - Country:US
Mailing Address - Phone:787-735-7110
Mailing Address - Fax:787-991-3041
Practice Address - Street 1:CALLE JOSE C VAZQUEZ
Practice Address - Street 2:EDIFICIO PROFESIONAL OFICINA 202 HOSPITAL MENONITA
Practice Address - City:AIBONITO
Practice Address - State:PR
Practice Address - Zip Code:00705
Practice Address - Country:US
Practice Address - Phone:787-735-7110
Practice Address - Fax:787-991-3041
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-09
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15031208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRI36893Medicare UPIN
PR2-3112Medicare ID - Type Unspecified