Healthcare Provider Details

I. General information

NPI: 1336769884
Provider Name (Legal Business Name): OTILIO JOSE RIVERA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2020
Last Update Date: 01/06/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARRETERA 22 BARRIO MONACILLOS, RIO PIEDRAS
SAN JUAN PR
00919
US

IV. Provider business mailing address

PO BOX 2052
ARECIBO PR
00613-2052
US

V. Phone/Fax

Practice location:
  • Phone: 787-777-3232
  • Fax:
Mailing address:
  • Phone: 787-397-0850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number15901
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: