Healthcare Provider Details

I. General information

NPI: 1295254290
Provider Name (Legal Business Name): NELITZA IVEMARIS RIVERA VEGA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2017
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SAN JORGE MEDICAL OFFICE BLDG SUITE 401 252 SAN JORGE ST.
SAN JUAN PR
00912
US

IV. Provider business mailing address

SAN JORGE MEDICAL OFFICE BLDG. SUITE 401 252 SAN JORGE ST.
SAN JUAN PR
00912
US

V. Phone/Fax

Practice location:
  • Phone: 787-726-1484
  • Fax:
Mailing address:
  • Phone: 787-726-1484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberBP1006738
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number24468
License Number StatePR
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number321902
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberME167900
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: