Provider Demographics
NPI:1578777439
Name:RIVERA, EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
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 1:301 LIPPINCOTT DR STE 410
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4197
Mailing Address - Country:US
Mailing Address - Phone:856-355-0340
Mailing Address - Fax:856-355-0330
Practice Address - Street 1:218A SUNSET RD
Practice Address - Street 2:
Practice Address - City:WILLINGBORO
Practice Address - State:NJ
Practice Address - Zip Code:08046-1110
Practice Address - Country:US
Practice Address - Phone:609-835-3056
Practice Address - Fax:609-835-3061
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY249580207R00000X
NJ25MA08177400207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03014326Medicaid
NJ0155578Medicaid
NJP01069999OtherRAILROAD MEDICARE
NJP01069999OtherRAILROAD MEDICARE
NY03014326Medicaid
NYA400022212Medicare PIN
NYA400022212Medicare PIN
NJ0155578Medicaid