Healthcare Provider Details

I. General information

NPI: 1073733127
Provider Name (Legal Business Name): IKSEN RIVERA-MORALES M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2007
Last Update Date: 02/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 AVE FD ROOSEVELT DIVISION DE RECURSOS HUMANOS, TRIPLE-S MANAGEMENT CORP
SAN JUAN PR
00920-2717
US

IV. Provider business mailing address

PO BOX 4291 BAY GDNS STATION
BAYAMON PR
00958-1291
US

V. Phone/Fax

Practice location:
  • Phone: 787-380-4111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number2589
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number11264
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: