Provider Demographics
NPI:1275175465
Name:RIVERA, ROLANDO
Entity Type:Individual
Prefix:
First Name:ROLANDO
Middle Name:
Last Name:RIVERA
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 1:134 LAKEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COVENTRY
Mailing Address - State:CT
Mailing Address - Zip Code:06238-2721
Mailing Address - Country:US
Mailing Address - Phone:860-235-6887
Mailing Address - Fax:
Practice Address - Street 1:STORRS CONNECTICUT
Practice Address - Street 2:
Practice Address - City:STORRS
Practice Address - State:CT
Practice Address - Zip Code:06269-0001
Practice Address - Country:US
Practice Address - Phone:860-486-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-09
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty