Provider Demographics
NPI:1457428096
Name:RIVERA, EDUARDO G (MD)
Entity Type:Individual
Prefix:
First Name:EDUARDO
Middle Name:G
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 1:122 DEMAREE DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-4622
Mailing Address - Country:US
Mailing Address - Phone:812-265-9191
Mailing Address - Fax:812-265-1050
Practice Address - Street 1:122 DEMAREE DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250-4622
Practice Address - Country:US
Practice Address - Phone:812-265-9191
Practice Address - Fax:812-265-1050
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01050279207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN065504OtherCOLUMBUS SIHO ID
KY50007573Medicaid
IN7514003OtherAETNA PROVIDER NUMBER
IN000000368119OtherANTHEM BCBS IN PROV NUMB
IN20897OtherIN HEALTH NETWORK ID
IN185140DMedicare ID - Type Unspecified
IN065504OtherCOLUMBUS SIHO ID
ING93466Medicare UPIN