Provider Demographics
NPI:1083669618
Name:RIVERA, TARA (DO)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 RIDGE RD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:DAYTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08810-3300
Mailing Address - Country:US
Mailing Address - Phone:732-329-4800
Mailing Address - Fax:732-329-0445
Practice Address - Street 1:3626 ROUTE 1 N
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:NJ
Practice Address - Zip Code:08540-5922
Practice Address - Country:US
Practice Address - Phone:609-243-0445
Practice Address - Fax:609-452-7577
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07195500207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8291201Medicaid
NJH58267Medicare UPIN
NJ8291201Medicaid