Provider Demographics
NPI:1386816726
Name:RIVERA, ANGELA (MD)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:ANGELA
Other - Middle Name:
Other - Last Name:DIAZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:320 E 94TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-5604
Mailing Address - Country:US
Mailing Address - Phone:212-423-2900
Mailing Address - Fax:212-423-2920
Practice Address - Street 1:320 E 94TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-5604
Practice Address - Country:US
Practice Address - Phone:212-423-2900
Practice Address - Fax:212-423-2920
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-26
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY159699-1261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00987811Medicaid