Healthcare Provider Details

I. General information

NPI: 1346662947
Provider Name (Legal Business Name): HAIDY RIVERO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2014
Last Update Date: 10/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 DEKALB AVE
BROOKLYN NY
11201-5425
US

IV. Provider business mailing address

121 DEKALB AVE
BROOKLYN NY
11201-5425
US

V. Phone/Fax

Practice location:
  • Phone: 718-250-8444
  • Fax:
Mailing address:
  • Phone: 718-250-8444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number273009
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: