Provider Demographics
NPI:1437104957
Name:RIVERA, VIVIAN T (MD)
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:T
Last Name:RIVERA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 AVE MARGINAL KENNEDY
Mailing Address - Street 2:
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00968-1746
Mailing Address - Country:US
Mailing Address - Phone:973-202-0198
Mailing Address - Fax:787-620-5761
Practice Address - Street 1:280 AVE MARGINAL KENNEDY
Practice Address - Street 2:
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00968-1746
Practice Address - Country:US
Practice Address - Phone:973-202-0198
Practice Address - Fax:787-620-5761
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA073652002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8906904Medicaid
NJ3000133615Medicare PIN
NJ8906904Medicaid
NJ058997UN4Medicare PIN
NJ058997A2VMedicare PIN
H36500Medicare UPIN
NJ058997CQHMedicare PIN