1114033511 NPI number — DR. ANTONIO RIVERA MD

Table of content: DR. ANTONIO RIVERA MD (NPI 1114033511)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114033511 NPI number — DR. ANTONIO RIVERA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RIVERA
Provider First Name:
ANTONIO
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1114033511
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/02/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 560727
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKLEDGE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32956
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-449-1112
Provider Business Mailing Address Fax Number:
321-449-1172

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
840 EXECUTIVE LN STE 120
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKLEDGE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32955-3519
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-449-1112
Provider Business Practice Location Address Fax Number:
321-449-1172
Provider Enumeration Date:
08/21/2006

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: 208100000X , with the licence number:  ME58006 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 12311 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 056326900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 942315600 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".