1215903745 NPI number — WANDA L RIVERA BOU M.D.

Table of content: WANDA L RIVERA BOU M.D. (NPI 1215903745)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215903745 NPI number — WANDA L RIVERA BOU M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RIVERA BOU
Provider First Name:
WANDA
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215903745
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 596
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUQUILLO
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00773-0596
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-487-2169
Provider Business Mailing Address Fax Number:
787-487-2169

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CARR #3 K.M. 8.3 AVE. 65 INFANTERIA
Provider Second Line Business Practice Location Address:
HOSPITAL UPR
Provider Business Practice Location Address City Name:
CAROLINA
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-757-1800
Provider Business Practice Location Address Fax Number:
787-750-0930
Provider Enumeration Date:
02/24/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  12963 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)