Provider Demographics
NPI:1073591665
Name:RIVERA, WANDA (MD)
Entity Type:Individual
Prefix:DR
First Name:WANDA
Middle Name:
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 1:9910 FRANKLIN SQUARE DR # 2110
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21236-4902
Mailing Address - Country:US
Mailing Address - Phone:410-933-5412
Mailing Address - Fax:
Practice Address - Street 1:1132 ANNAPOLIS RD
Practice Address - Street 2:
Practice Address - City:ODENTON
Practice Address - State:MD
Practice Address - Zip Code:21113
Practice Address - Country:US
Practice Address - Phone:410-874-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0062879207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD7312772OtherAETNA FEE FOR SERVICE
MDP17025OtherCAREFIRST MPOS
MD7605-0080OtherCAREFIRST BLUECHOICE
MD651290-01OtherCAREFIRST MD RENDERING
MD8146200OtherMAMSI PRIMARY CARE
MD1172181OtherAETNA CAPITATED
MD2146200OtherMAMSI SPECIALIST
MD2610730OtherUHC PROVIDER NUMBER
MD409667300Medicaid
MD2610730OtherUHC PROVIDER NUMBER
MD409667300Medicaid