Provider Demographics
NPI:1760986715
Name:RIVERA, KEVIN JOHN REYES (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN JOHN
Middle Name:REYES
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 1:196 WILLOUGHBY ST APT 20Q
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-7643
Mailing Address - Country:US
Mailing Address - Phone:319-576-8414
Mailing Address - Fax:
Practice Address - Street 1:1819 BERGEN ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11233-4513
Practice Address - Country:US
Practice Address - Phone:718-221-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-22
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR-112232084P0800X
IAR-120172084P0804X
IAMD-496212084P0804X
390200000X
NY3223732084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program