Provider Demographics
NPI:1184677502
Name:RIVERA, EDGARDO BERNARDINO (MD)
Entity Type:Individual
Prefix:DR
First Name:EDGARDO
Middle Name:BERNARDINO
Last Name:RIVERA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:331 OXFORD BLVD S
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-5411
Mailing Address - Country:US
Mailing Address - Phone:718-721-9292
Mailing Address - Fax:718-721-3222
Practice Address - Street 1:3501 30TH AVE
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-4662
Practice Address - Country:US
Practice Address - Phone:718-721-9292
Practice Address - Fax:718-721-3222
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY153520207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB80126Medicare UPIN