Provider Demographics
NPI:1821089350
Name:VIVACQUA, RAYMOND J (MD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:J
Last Name:VIVACQUA
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 1:131 PADDOCK LN
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-1109
Mailing Address - Country:US
Mailing Address - Phone:610-619-7420
Mailing Address - Fax:610-876-6923
Practice Address - Street 1:1 MEDICAL CENTER BLVD
Practice Address - Street 2:VIVACQUA PAVILION SUITE 341
Practice Address - City:UPLAND
Practice Address - State:PA
Practice Address - Zip Code:19013-3902
Practice Address - Country:US
Practice Address - Phone:610-619-7420
Practice Address - Fax:610-876-6923
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD027985L207RH0003X
NJ25MA07633500207RH0003X
DEC10009188207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000661297-0002Medicaid
NJ072972RVOMedicare PIN
PA000661297-0002Medicaid
PA1009510001Medicare NSC
PA018120G48Medicare PIN