Healthcare Provider Details

I. General information

NPI: 1508212879
Provider Name (Legal Business Name): JONATHAN L RIVERA GONZALEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2016
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 S GOLDENROD RD STE B
ORLANDO FL
32822-8113
US

IV. Provider business mailing address

425 W COLONIAL DR STE 303
ORLANDO FL
32804-6863
US

V. Phone/Fax

Practice location:
  • Phone: 407-362-0148
  • Fax: 407-271-8436
Mailing address:
  • Phone: 210-630-2207
  • Fax: 407-271-8436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number21828
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number21828
License Number StatePR
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME146934
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: