Healthcare Provider Details

I. General information

NPI: 1295821031
Provider Name (Legal Business Name): MODESTO SANTOS RIVERA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 SOLOMONS ISLAND RD.
PRINCE FREDERICK MD
20678
US

IV. Provider business mailing address

806 SOLOMONS ISLAND ROAD NORTH
PRINCE FREDERICK MD
20678
US

V. Phone/Fax

Practice location:
  • Phone: 410-535-4242
  • Fax: 410-535-4983
Mailing address:
  • Phone: 410-535-4242
  • Fax: 410-535-4983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberD19963
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: