Healthcare Provider Details

I. General information

NPI: 1497742316
Provider Name (Legal Business Name): JOSE SANDALIO RIVERA IRIZARRY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 09/02/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 CALLE MORSE
ARROYO PR
00714-2350
US

IV. Provider business mailing address

339 CYPRESS PKWY STE 110
KISSIMMEE FL
34759-3315
US

V. Phone/Fax

Practice location:
  • Phone: 787-839-3980
  • Fax: 787-271-2515
Mailing address:
  • Phone: 407-343-5000
  • Fax: 407-343-5199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number11901
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: