Provider Demographics
NPI:1851761555
Name:RIVERA VERGARA, RAYMOND MANUEL
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:MANUEL
Last Name:RIVERA VERGARA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4720 PINE ST APT C3
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-1840
Mailing Address - Country:US
Mailing Address - Phone:267-595-1655
Mailing Address - Fax:302-233-7475
Practice Address - Street 1:4720 PINE ST APT C3
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19143-1840
Practice Address - Country:US
Practice Address - Phone:267-595-1655
Practice Address - Fax:302-233-7475
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-07
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD478007208D00000X
PR21515208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR21515OtherGENERAL DOCTOR
PR21515OtherNEUROLOGY