Healthcare Provider Details

I. General information

NPI: 1780664177
Provider Name (Legal Business Name): LUIS R RIVERA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 11/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11501 SW 40TH ST
MIAMI FL
33165-3313
US

IV. Provider business mailing address

8600 NW 41ST ST
DORAL FL
33166-6202
US

V. Phone/Fax

Practice location:
  • Phone: 305-642-5366
  • Fax: 305-631-3828
Mailing address:
  • Phone: 305-642-5366
  • Fax: 305-631-3828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberG0526
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberME109084
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: