Provider Demographics
NPI:1437231115
Name:RIVERA, EDMUNDO I (MD)
Entity Type:Individual
Prefix:DR
First Name:EDMUNDO
Middle Name:I
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 1:250 TREEMONT DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-7945
Mailing Address - Country:US
Mailing Address - Phone:386-774-6001
Mailing Address - Fax:386-774-6044
Practice Address - Street 1:296 TREEMONT DR
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-7945
Practice Address - Country:US
Practice Address - Phone:386-774-6001
Practice Address - Fax:386-774-6044
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME624002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL17826Medicare ID - Type UnspecifiedPROVIDER