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General NPI Number Information
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NPI Number | 1922325026
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Entity Type | Organization
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Legal Business Name | MODESTO S RIVERA III MD PA
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Dates
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Enumeration Date | 04/28/2010
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Last Update Date | 04/28/2010
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Provider Practice Location Address
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Address Line | 806 SOLOMONS ISLAND RD N
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City | PRNC FREDERCK
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State | MD
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Zip | 20678-3919
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Country | US
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Telephone | 410-535-3424
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Fax | 410-535-4983
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Provider Business Mailing Address
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Address Line | 806 SOLOMONS ISLAND RD N
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City | PRNC FREDERCK
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State | MD
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Zip | 20678-3919
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Country | US
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Telephone | 410-535-3424
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Fax | 410-535-4983
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MODESTO SANTOS RIVERA III
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Credential | M.D.
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Telephone | 410-535-4242
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | D19963
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License Number State | MD
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