Healthcare Provider Details

I. General information

NPI: 1174539134
Provider Name (Legal Business Name): EDWIN RIVERA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W MORENO ST
PENSACOLA FL
32501-2316
US

IV. Provider business mailing address

PO BOX 622047
ORLANDO FL
32862-2047
US

V. Phone/Fax

Practice location:
  • Phone: 850-436-4951
  • Fax: 850-438-6767
Mailing address:
  • Phone: 850-436-4951
  • Fax: 850-438-6767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberME0077277
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License NumberME0077277
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License NumberME077277
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME0077277
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code2085R0205X
TaxonomyRadiological Physics Physician
License NumberME0077277
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License NumberME0077277
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: