Provider Demographics
NPI:1265561070
Name:RIVERA, EDGARDO (M D)
Entity type:Individual
Prefix:
First Name:EDGARDO
Middle Name:
Last Name:RIVERA
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3269 N STOCKTON HILL RD
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3619
Mailing Address - Country:US
Mailing Address - Phone:928-263-5666
Mailing Address - Fax:928-692-4648
Practice Address - Street 1:3269 N STOCKTON HILL RD
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3619
Practice Address - Country:US
Practice Address - Phone:928-263-5666
Practice Address - Fax:928-692-4648
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1479207RX0202X
AZ44221207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8W1057OtherBLUE CROSS BLUE SHIELD
TXP00442974OtherRAILROAD MEDICARE
TX041341102Medicaid
AZZ147355Medicare PIN
AZZ145021Medicare PIN
TX8J4383Medicare PIN