=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265582068
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSE ALBERTO RIVERA-RODRIGUEZ MEDICINE DOCTOR
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 361 SARGENTO LUIS MEDINA URB.ROOSEVELT
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00918-3817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-763-8216
-----------------------------------------------------
Fax | 787-294-1083
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 361 SARGENTO LUIS MEDINA ST. NUMBER 1
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00918-3817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-763-8216
-----------------------------------------------------
Fax | 787-294-1083
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 4671
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------