Healthcare Provider Details

I. General information

NPI: 1215976782
Provider Name (Legal Business Name): LUIS RAFAEL NIEVES GONZALEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 01/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARRETERA 2 KM 112.2 BO MORA
ISABELA PR
00662-4800
US

IV. Provider business mailing address

PO BOX 484
ISABELA PR
00662-0484
US

V. Phone/Fax

Practice location:
  • Phone: 787-830-8866
  • Fax: 787-830-8866
Mailing address:
  • Phone: 787-407-4424
  • Fax: 787-830-8866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number15589
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: