Healthcare Provider Details

I. General information

NPI: 1841567492
Provider Name (Legal Business Name): LEONARDO RAMOS RIVERA JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2011
Last Update Date: 02/26/2020
Certification Date: 02/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18730 HILLSIDE AVE
JAMAICA NY
11432-3216
US

IV. Provider business mailing address

182 INDUSTRIAL RD STE 107
GLEN ROCK PA
17327-8626
US

V. Phone/Fax

Practice location:
  • Phone: 718-264-1111
  • Fax: 718-264-2195
Mailing address:
  • Phone: 717-759-5148
  • Fax: 717-759-5435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number264995
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: