Provider Demographics
NPI:1477839306
Name:EDMUNDO I RIVERA MD PA
Entity Type:Organization
Organization Name:EDMUNDO I RIVERA MD PA
Other - Org Name:WEST VOLUSIA PSYCHIATRIC ASSOCIATES
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EDMUNDO
Authorized Official - Middle Name:I
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-774-6001
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 1:250 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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME624002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL17826AMedicare UPIN