Provider Demographics
NPI:1427396209
Name:RIVLIN, KWAN THANAPORN (MD)
Entity type:Individual
Prefix:DR
First Name:KWAN
Middle Name:THANAPORN
Last Name:RIVLIN
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:THANAPORN
Other - Middle Name:
Other - Last Name:RIVLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:200 BOWMAN DRIVE
Mailing Address - Street 2:SUITEE385
Mailing Address - City:MOORESTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08043
Mailing Address - Country:US
Mailing Address - Phone:856-840-4534
Mailing Address - Fax:
Practice Address - Street 1:200 BOWMAN DR STE E385
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-9638
Practice Address - Country:US
Practice Address - Phone:856-840-4534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-29
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA255025207R00000X
NJ25MA09669000208M00000X, 207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0569321Medicaid