Basic Information
| Provider Information | |||||||||
| NPI: | 1124554449 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIVERA NAZARIO | ||||||||
| FirstName: | IVAN | ||||||||
| MiddleName: | AUGUSTO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 191811 | ||||||||
| Address2: | |||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009191811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877634149 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 150 AVE AMERICO MIRANDA BO MONASILLO | ||||||||
| Address2: | AREA DE CENTRO MEDICO METROPOLITANO | ||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009350001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877634149 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2017 | ||||||||
| LastUpdateDate: | 08/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 21051 | PR | N | Allopathic & Osteopathic Physicians | General Practice | 390200000X | 21051 | PR | Y | 193400000X SINGLE SPECIALTY GROUP | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.