Provider Demographics
NPI:1104827914
Name:PRIMAVERA, RICHARD (DPM CWS FACFAOM)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:PRIMAVERA
Suffix:
Gender:M
Credentials:DPM CWS FACFAOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 REDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:OCEAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07712-8702
Mailing Address - Country:US
Mailing Address - Phone:732-610-4885
Mailing Address - Fax:
Practice Address - Street 1:179 NORWOOD AVE
Practice Address - Street 2:
Practice Address - City:LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07740-5403
Practice Address - Country:US
Practice Address - Phone:732-222-3917
Practice Address - Fax:732-222-0324
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD01214213E00000X, 213EP0504X, 213EP1101X, 213ER0200X, 213ES0000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP0504XPodiatric Medicine & Surgery Service ProvidersPodiatristPublic Medicine
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiology
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJT73022Medicare UPIN