Provider Demographics
NPI:1902146996
Name:JOHN E. RIVERA JR., M.D., LLC
Entity type:Organization
Organization Name:JOHN E. RIVERA JR., M.D., LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:860-621-5554
Mailing Address - Street 1:PO BOX 770
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 TURNPIKE
Practice Address - Street 2:
Practice Address - City:MILLDALE
Practice Address - State:CT
Practice Address - Zip Code:06467
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:2013-02-27
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT042567207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTI09328Medicare UPIN