Provider Demographics
NPI:1992297675
Name:RIVERA, JESUS M
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:M
Last Name:RIVERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:E-13 PARKSIDE 1
Mailing Address - Street 2:APT 6-C
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00968-3324
Mailing Address - Country:US
Mailing Address - Phone:787-378-0656
Mailing Address - Fax:
Practice Address - Street 1:CARRETERA 159 KM 13.1
Practice Address - Street 2:LOCAL 5
Practice Address - City:COROZAL
Practice Address - State:PR
Practice Address - Zip Code:00783
Practice Address - Country:US
Practice Address - Phone:787-378-0656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-30
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR886156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR660899821Medicaid