Healthcare Provider Details

I. General information

NPI: 1508854845
Provider Name (Legal Business Name): AJNEB RIVALTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 11/13/2023
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CAROLINA SHOPPING COURT, SUITE 201 A
CAROLINA PR
00985
US

IV. Provider business mailing address

CAMINO EDUVIGES RIVERA CARR ESTATAL 175 KM 9.2
TRUJILLO ALTO PR
00977
US

V. Phone/Fax

Practice location:
  • Phone: 787-767-8758
  • Fax: 844-759-2966
Mailing address:
  • Phone: 787-755-6642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number15638
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: