Provider Demographics
NPI:1114033511
Name:RIVERA, ANTONIO (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTONIO
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 560727
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32956
Mailing Address - Country:US
Mailing Address - Phone:321-449-1112
Mailing Address - Fax:321-449-1172
Practice Address - Street 1:840 EXECUTIVE LN STE 120
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3519
Practice Address - Country:US
Practice Address - Phone:321-449-1112
Practice Address - Fax:321-449-1172
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME58006208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
12311OtherBCBS
FL056326900Medicaid
942315600OtherCIGNA
942315600OtherCIGNA
12311AMedicare ID - Type Unspecified