Provider Demographics
NPI:1699731661
Name:RIVERA, JOHN EDWIN (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EDWIN
Last Name:RIVERA
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1591 MERIDEN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-4208
Mailing Address - Country:US
Mailing Address - Phone:860-621-6335
Mailing Address - Fax:
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
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT026829207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT026829OtherSTATE MEDICAL LICENSE
CTB84378Medicare UPIN