Healthcare Provider Details

I. General information

NPI: 1598405581
Provider Name (Legal Business Name): STEPHANIE RIVERA TAVAREZ DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2022
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PASEO SAN PABLO
BAYAMON PR
00961-7019
US

IV. Provider business mailing address

100 PASEO SAN PABLO
BAYAMON PR
00961-7019
US

V. Phone/Fax

Practice location:
  • Phone: 787-667-4829
  • Fax:
Mailing address:
  • Phone: 787-667-4829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number000122
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: