Provider Demographics
NPI:1619439965
Name:RIVERA, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
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 1:1530 CORNERSTONE BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-7129
Mailing Address - Country:US
Mailing Address - Phone:386-310-3529
Mailing Address - Fax:
Practice Address - Street 1:60 MEMORIAL MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-5980
Practice Address - Country:US
Practice Address - Phone:386-586-4243
Practice Address - Fax:386-586-4620
Is Sole Proprietor?:No
Enumeration Date:2019-04-04
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME149819207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine