Provider Demographics
NPI:1740366640
Name:RIVERA COUT, LAURA (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:RIVERA COUT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 BOYLE RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-1929
Mailing Address - Country:US
Mailing Address - Phone:631-696-2000
Mailing Address - Fax:631-696-2003
Practice Address - Street 1:243 BOYLE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:SELDEN
Practice Address - State:NY
Practice Address - Zip Code:11784-1929
Practice Address - Country:US
Practice Address - Phone:631-696-2000
Practice Address - Fax:631-696-2003
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY284030-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1K3066OtherHEALTHNET
2014484001OtherKEYSTONE
P858418OtherOXFORD
H00860Medicare UPIN
P858418OtherOXFORD