Healthcare Provider Details

I. General information

NPI: 1215992276
Provider Name (Legal Business Name): WALDEMAR RAFAEL RIVERA JIMENEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 10/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CALLE TOMAS DAVILA
BARCELONETA PR
00617-2736
US

IV. Provider business mailing address

PO BOX 359
BARCELONETA PR
00617-0359
US

V. Phone/Fax

Practice location:
  • Phone: 787-846-6890
  • Fax:
Mailing address:
  • Phone: 787-846-4447
  • Fax: 787-970-5458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number15969
License Number StatePR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier23836RI
Identifier TypeOTHER
Identifier StatePR
Identifier IssuerSSS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: