Provider Demographics
NPI:1205123593
Name:RIVERA, CARMELO JR (RD)
Entity type:Individual
Prefix:MR
First Name:CARMELO
Middle Name:
Last Name:RIVERA
Suffix:JR
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1226 SHERMAN AVE
Mailing Address - Street 2:APT 21
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10456-3015
Mailing Address - Country:US
Mailing Address - Phone:646-641-7427
Mailing Address - Fax:
Practice Address - Street 1:1650 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-7606
Practice Address - Country:US
Practice Address - Phone:718-518-5026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006442-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered