Provider Demographics
NPI:1790793834
Name:RIVERA, GREGORY (DPM)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:
Last Name:RIVERA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:656 W 183RD ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-3806
Mailing Address - Country:US
Mailing Address - Phone:212-795-2261
Mailing Address - Fax:212-795-2671
Practice Address - Street 1:656 W 183RD ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-3806
Practice Address - Country:US
Practice Address - Phone:212-795-2261
Practice Address - Fax:212-795-2671
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005520213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02487227Medicaid
P0159FW281Medicare PIN
5986550001Medicare NSC
P01591Medicare PIN
040913Medicare PIN
U79773Medicare UPIN
P01592Medicare PIN
P015910Medicare PIN