Basic Information
| Provider Information | |||||||||
| NPI: | 1588758676 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIOS | ||||||||
| FirstName: | PASTOR | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 449 SE BAYA DRIVE | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867550500 | ||||||||
| FaxNumber: | 3867559217 | ||||||||
| Practice Location | |||||||||
| Address1: | 449 SE BAYA DRIVE | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867550500 | ||||||||
| FaxNumber: | 3867559217 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | ME45687 | FL | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 07742 | 01 | FL | BCBS PROVIDER NUMBER | OTHER | 030461 | 01 | FL | AVMED PROVIDER NUMBER | OTHER |