Healthcare Provider Details

I. General information

NPI: 1184677502
Provider Name (Legal Business Name): EDGARDO BERNARDINO RIVERA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 30TH AVE
ASTORIA NY
11103-4662
US

IV. Provider business mailing address

331 OXFORD BLVD S
GARDEN CITY NY
11530-5411
US

V. Phone/Fax

Practice location:
  • Phone: 718-721-9292
  • Fax: 718-721-3222
Mailing address:
  • Phone: 718-721-9292
  • Fax: 718-721-3222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number153520
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: