Provider Demographics
NPI:1902469760
Name:RIVERA, ANDREA VERGHESE (MD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:VERGHESE
Last Name:RIVERA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:
Other - Last Name:VERGHESE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1101 LUDLOW ST APT 1017
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4266
Mailing Address - Country:US
Mailing Address - Phone:610-297-5798
Mailing Address - Fax:
Practice Address - Street 1:833 CHESTNUT ST STE 220
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4405
Practice Address - Country:US
Practice Address - Phone:215-955-8465
Practice Address - Fax:215-955-2516
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-17
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT218475390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program