Provider Demographics
NPI:1548234412
Name:RIVERA, SALOMON
Entity Type:Individual
Prefix:
First Name:SALOMON
Middle Name:
Last Name:RIVERA
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 1:698 W 204TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10034-3027
Mailing Address - Country:US
Mailing Address - Phone:212-942-3830
Mailing Address - Fax:
Practice Address - Street 1:698 W 204TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10034-3027
Practice Address - Country:US
Practice Address - Phone:212-942-3830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY135118174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC05265Medicare UPIN
NY08A841Medicare ID - Type Unspecified
NY00399679Medicare ID - Type Unspecified