1407875065 NPI number — DR. ABRAHAM RIVERA MD

Table of content: DR. ABRAHAM RIVERA MD (NPI 1407875065)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407875065 NPI number — DR. ABRAHAM RIVERA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RIVERA
Provider First Name:
ABRAHAM
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:
1407875065
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4730 N HABANA AVE
Provider Second Line Business Mailing Address:
STE 204
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33614-7163
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-549-2134
Provider Business Mailing Address Fax Number:
813-864-4436

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3450 E FLETCHER AVE
Provider Second Line Business Practice Location Address:
STE 350
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33613-4655
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-739-7495
Provider Business Practice Location Address Fax Number:
813-864-0788
Provider Enumeration Date:
07/18/2006

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: 207L00000X , with the licence number:  ME93446 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0000X , with the licence number: ME93446 , 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: 274485600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01099802 . This is a "R&R MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 274485600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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