Provider Demographics
NPI:1154387264
Name:JOHN E. RIVERA, M.D., P.C.
Entity type:Organization
Organization Name:JOHN E. RIVERA, M.D., P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-621-5554
Mailing Address - Street 1:1753 MERIDEN-WATERBURY RD
Mailing Address - Street 2:
Mailing Address - City:MILLDALE
Mailing Address - State:CT
Mailing Address - Zip Code:06467-0770
Mailing Address - Country:US
Mailing Address - Phone:860-621-5554
Mailing Address - Fax:860-621-3833
Practice Address - Street 1:1753 MERIDEN-WATERBURY RD
Practice Address - Street 2:
Practice Address - City:MILLDALE
Practice Address - State:CT
Practice Address - Zip Code:06467-0770
Practice Address - Country:US
Practice Address - Phone:860-621-5554
Practice Address - Fax:860-621-3833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT026829207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT042567OtherLIC-JOHN E. RIVERA, JR MD
CT026829OtherLIC-JOHN E. RIVERA, M.D.
CTI09328Medicare UPIN
CT026829OtherLIC-JOHN E. RIVERA, M.D.