Healthcare Provider Details

I. General information

NPI: 1821520057
Provider Name (Legal Business Name): ISRAEL NIEVES RODRIGUEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 02/13/2020
Certification Date: 02/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR. #2 KM 57.8
BARCELONETA PR
00617
US

IV. Provider business mailing address

2 CALLE ALMONTE APT 1105
SAN JUAN PR
00926-2443
US

V. Phone/Fax

Practice location:
  • Phone: 787-486-7482
  • Fax:
Mailing address:
  • Phone: 787-486-7482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number21681
License Number StatePR

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: