Healthcare Provider Details

I. General information

NPI: 1992882815
Provider Name (Legal Business Name): JOSE D RIVERA MIRANDA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 03/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2431 AVE LAS AMERICAS 306 EDIFICIO PORRATA PILA
PONCE PR
00717-2113
US

IV. Provider business mailing address

2431 AVE LAS AMERICAS 306 EDIFICIO PORRATA PILA
PONCE PR
00717-2113
US

V. Phone/Fax

Practice location:
  • Phone: 787-841-0574
  • Fax: 787-841-0574
Mailing address:
  • Phone: 787-841-0574
  • Fax: 787-841-0574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number12341
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: