Provider Demographics
NPI:1447278056
Name:RIVERA, PEDRO IVAN (MD)
Entity type:Individual
Prefix:
First Name:PEDRO
Middle Name:IVAN
Last Name:RIVERA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PETER
Other - Middle Name:
Other - Last Name:RIVERA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:P.O. BOX 325
Mailing Address - Street 2:
Mailing Address - City:ARROYO
Mailing Address - State:PR
Mailing Address - Zip Code:00714-9999
Mailing Address - Country:US
Mailing Address - Phone:787-790-1891
Mailing Address - Fax:208-567-7745
Practice Address - Street 1:400 AMERICO MIRANDA AVE
Practice Address - Street 2:RIO PIEDRAS STATION
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00928-1405
Practice Address - Country:US
Practice Address - Phone:787-766-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14748207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAD79699Medicare UPIN