Healthcare Provider Details

I. General information

NPI: 1962306092
Provider Name (Legal Business Name): GUSTAVO ALEJANDRO RIVERA DAVID DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2026
Last Update Date: 10/03/2026
Certification Date: 10/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2346 MASCOUTAH AVE
BELLEVILLE IL
62220-3499
US

IV. Provider business mailing address

PO BOX 2492
COAMO PR
00769-4492
US

V. Phone/Fax

Practice location:
  • Phone: 618-277-6282
  • Fax:
Mailing address:
  • Phone: 787-988-1761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070041217
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: