MEDICARE: DR. SANTOS . RIVERA JR. DSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	R23377-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	R23377-1	OTHER	NY	NYS LICENSE NUMBER

General Provider Information

NPI Number	:	1205056751
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SANTOS . RIVERA JR. DSW

Provider Business Mailing Address
First Line	:	761 49TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11220-2206
Country	:	US
Telephone Number	:	718-438-8561
Fax Number	:

Provider Business Practice Location Address
First Line	:	1048 49TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11219-2917
Country	:	US
Telephone Number	:	718-438-8561
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/26/2007
Last Update Date	:	07/08/2007

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