Provider Demographics
NPI:1992741326
Name:RIVERA, CARLOS GALLEGOS (MD,)
Entity type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:GALLEGOS
Last Name:RIVERA
Suffix:
Gender:M
Credentials:MD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 DAKARLA DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07748-3171
Mailing Address - Country:US
Mailing Address - Phone:732-957-0408
Mailing Address - Fax:
Practice Address - Street 1:9 MEMORIAL PKWY
Practice Address - Street 2:
Practice Address - City:LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07740-6701
Practice Address - Country:US
Practice Address - Phone:732-728-7010
Practice Address - Fax:732-728-0704
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06184200173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ31D0941981OtherCLIA NUMBER
NJ223601506OtherTAX ID
NJ6635008Medicaid
NJ6635008Medicaid
NJ223601506OtherTAX ID