Basic Information
| Provider Information | |||||||||
| NPI: | 1720044811 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIVERA | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | EDWIN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 YORK ST | ||||||||
| Address2: | CB-2041 | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065048900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036884748 | ||||||||
| FaxNumber: | 2036884740 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 YORK ST CB-2041 | ||||||||
| Address2: | HOSPITALIST SERVICE | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036884748 | ||||||||
| FaxNumber: | 2036884740 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 03/10/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 042567 | CT | Y | Allopathic & Osteopathic Physicians | Hospitalist | 207Q00000X | 042567 | CT | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 042567 | 01 | CT | STATE MEDICAL LICENSE | OTHER |