Provider Demographics
NPI:1922088053
Name:CLARA M. RIVERA PHYSICIAN PC
Entity Type:Organization
Organization Name:CLARA M. RIVERA PHYSICIAN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETER
Authorized Official - Prefix:
Authorized Official - First Name:CLARA
Authorized Official - Middle Name:M
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-261-1759
Mailing Address - Street 1:11247 QUEENS BLVD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-7417
Mailing Address - Country:US
Mailing Address - Phone:718-261-1759
Mailing Address - Fax:
Practice Address - Street 1:11247 QUEENS BLVD
Practice Address - Street 2:SUITE 106
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-7417
Practice Address - Country:US
Practice Address - Phone:718-261-1759
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-17
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY161107174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01055009Medicaid
NY01055009Medicaid
NY38F221Medicare ID - Type Unspecified