Healthcare Provider Details

I. General information

NPI: 1225788821
Provider Name (Legal Business Name): JOHN-LUKE RIVERA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2022
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 W HARRISON ST
CHICAGO IL
60612-3705
US

IV. Provider business mailing address

2121 W HARRISON ST
CHICAGO IL
60612-3705
US

V. Phone/Fax

Practice location:
  • Phone: 312-666-0500
  • Fax:
Mailing address:
  • Phone: 312-666-0500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZF0201X
TaxonomyForensic Pathology Physician
License Number036178263
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number125.080873
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: