Provider Demographics
NPI:1174539134
Name:RIVERA, EDWIN (MD)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:
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:PO BOX 622047
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32862-2047
Mailing Address - Country:US
Mailing Address - Phone:850-436-4951
Mailing Address - Fax:850-438-6767
Practice Address - Street 1:1000 W MORENO ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-2316
Practice Address - Country:US
Practice Address - Phone:850-436-4951
Practice Address - Fax:850-438-6767
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00772772085B0100X, 2085N0904X, 2085R0202X, 2085R0205X, 2085U0001X
FLME0772772085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0205XAllopathic & Osteopathic PhysiciansRadiologyRadiological Physics
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL35375OtherBCBS
AL51096831RIVOtherBCBS
AL51096831RIVMedicare ID - Type Unspecified
AL51096831RIVOtherBCBS