Healthcare Provider Details

I. General information

NPI: 1780708875
Provider Name (Legal Business Name): BASILISA RIVERA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 CALLE ZORZAL CHALETS DE BAIROA
CAGUAS PR
00727-1246
US

IV. Provider business mailing address

NO. 37 ZORZAL ST. CHALETS DE BAIROA
CAGUAS PR
00727-1246
US

V. Phone/Fax

Practice location:
  • Phone: 787-653-3434
  • Fax: 787-653-1753
Mailing address:
  • Phone: 787-653-3434
  • Fax: 787-653-1753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License Number11220
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: