MEDICARE: HECTOR J RIVERA JACQUEZ MD PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program	112769	GA
2	390200000X	Student in an Organized Health Care Education/Training Program	17389-I	PR

General Provider Information

NPI Number	:	1134910482
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HECTOR J RIVERA JACQUEZ MD PHD

Provider Business Mailing Address
First Line	:	1601 WATSON BLVD
Second Line	:
City	:	WARNER ROBINS
State	:	GA
Zip	:	31093-3431
Country	:	US
Telephone Number	:	478-922-4281
Fax Number	:

Provider Business Practice Location Address
First Line	:	1601 WATSON BLVD
Second Line	:
City	:	WARNER ROBINS
State	:	GA
Zip	:	31093-3431
Country	:	US
Telephone Number	:	478-922-4281
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/15/2025
Last Update Date	:	06/13/2026

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