1407881626 NPI number — DR. IVELISSE RIVERA-GODREAU M.D.

Table of content: DR. IVELISSE RIVERA-GODREAU M.D. (NPI 1407881626)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407881626 NPI number — DR. IVELISSE RIVERA-GODREAU M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RIVERA-GODREAU
Provider First Name:
IVELISSE
Provider Middle Name:
Provider Name Prefix Text:
DR.
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:
1407881626
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/19/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
635 MAIN ST
Provider Second Line Business Mailing Address:
ATTN: CREDENTIALING DPT
Provider Business Mailing Address City Name:
MIDDLETOWN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06457-2718
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-347-6971
Provider Business Mailing Address Fax Number:
860-638-6601

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
134 STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06450-3293
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-237-2229
Provider Business Practice Location Address Fax Number:
203-686-1677
Provider Enumeration Date:
07/12/2006

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: 207Q00000X , with the licence number:  047088 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: D400001144 . This is a "MEDICARE" identifier . This identifiers is of the category "OTHER".