Healthcare Provider Details

I. General information

NPI: 1093197683
Provider Name (Legal Business Name): J.R.A.GASTROENTEROLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2015
Last Update Date: 06/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AVE. PONCE DE LEON #735 TORRE MEDICA AUXILIO MUTUO SUITE #816
SAN JUAN PR
00917
US

IV. Provider business mailing address

138 AVE WINSTON CHURCHILL PMB 357
SAN JUAN PR
00926-6013
US

V. Phone/Fax

Practice location:
  • Phone: 787-765-1025
  • Fax:
Mailing address:
  • Phone: 787-763-1020
  • Fax: 787-250-1928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number17183
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code207RT0003X
TaxonomyTransplant Hepatology Physician
License Number17183
License Number StatePR

VIII. Authorized Official

Name: JOSE E. RIVERA-ACOSTA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 787-598-1555