Healthcare Provider Details

I. General information

NPI: 1083669618
Provider Name (Legal Business Name): TARA RIVERA D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3626 ROUTE 1 N
PRINCETON NJ
08540-5922
US

IV. Provider business mailing address

401 RIDGE RD SUITE 6
DAYTON NJ
08810-3300
US

V. Phone/Fax

Practice location:
  • Phone: 609-243-0445
  • Fax: 609-452-7577
Mailing address:
  • Phone: 732-329-4800
  • Fax: 732-329-0445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MB07195500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: