Provider Demographics
NPI:1720044811
Name:RIVERA, JOHN EDWIN JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EDWIN
Last Name:RIVERA
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:20 YORK ST
Mailing Address - Street 2:CB-2041
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06504-8900
Mailing Address - Country:US
Mailing Address - Phone:203-688-4748
Mailing Address - Fax:203-688-4740
Practice Address - Street 1:20 YORK ST CB-2041
Practice Address - Street 2:HOSPITALIST SERVICE
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06504
Practice Address - Country:US
Practice Address - Phone:203-688-4748
Practice Address - Fax:203-688-4740
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT042567208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT042567OtherSTATE MEDICAL LICENSE
CTI09328Medicare UPIN
CT080001681Medicare ID - Type Unspecified