Provider Demographics
NPI:1477287068
Name:RIVERA BOADLA, MARLON ELIU
Entity Type:Individual
Prefix:
First Name:MARLON
Middle Name:ELIU
Last Name:RIVERA BOADLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 LAWRENCE ST APT 10G
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-3864
Mailing Address - Country:US
Mailing Address - Phone:347-793-4718
Mailing Address - Fax:
Practice Address - Street 1:4802 10TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-2916
Practice Address - Country:US
Practice Address - Phone:718-283-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-11
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program