Basic Information
| Provider Information | |||||||||
| NPI: | 1124074323 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RIVERA GONZALEZ | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | URB TERRANOBA ST 1 G1 | ||||||||
| Address2: | |||||||||
| City: | GUAYNABO | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877082243 | ||||||||
| FaxNumber: | 7877082243 | ||||||||
| Practice Location | |||||||||
| Address1: | UNIVERSITY PEDIATRIC HOSPITAL | ||||||||
| Address2: | 6TH FLOOR NEONATOLOGY SECTION | ||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009191079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877773225 | ||||||||
| FaxNumber: | 7877585307 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 08/06/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 07/17/2007 | ||||||||
| NPIReactivationDate: | 08/06/2007 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 12398 | PR | Y | Other Service Providers | Specialist |
No ID Information.