Provider Demographics
NPI:1891993218
Name:RIVERA, MARCUS RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:RICHARD
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 1:725 IRVING AVE
Mailing Address - Street 2:CROUSE POB STE. 805
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1603
Mailing Address - Country:US
Mailing Address - Phone:315-464-8444
Mailing Address - Fax:315-464-8445
Practice Address - Street 1:725 IRVING AVE
Practice Address - Street 2:CROUSE POB STE. 805
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1603
Practice Address - Country:US
Practice Address - Phone:315-464-8444
Practice Address - Fax:315-464-8445
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2557822080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02888902Medicaid
NY02888902Medicaid