Provider Demographics
NPI:1649212978
Name:RIVERA, ANTONIO R (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:R
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 1:1126 ORMOND CT
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-2960
Mailing Address - Country:US
Mailing Address - Phone:703-532-1222
Mailing Address - Fax:703-532-5100
Practice Address - Street 1:6319 CASTLE PL
Practice Address - Street 2:STE 1 E
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22044-1907
Practice Address - Country:US
Practice Address - Phone:703-532-1222
Practice Address - Fax:703-532-5100
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101230403207R00000X
MDD0055635207R00000X
DCMD31691207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G01527A01Medicare ID - Type Unspecified
G99111Medicare UPIN