Provider Demographics
NPI:1538160890
Name:RIVERA, ROGER ANTONIO (MD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:ANTONIO
Last Name:RIVERA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:870 PALISADE AVE
Mailing Address - Street 2:STE 204
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-3419
Mailing Address - Country:US
Mailing Address - Phone:201-928-1093
Mailing Address - Fax:201-928-0842
Practice Address - Street 1:810 ABBOTT BLVD
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-4151
Practice Address - Country:US
Practice Address - Phone:201-224-3200
Practice Address - Fax:201-224-4045
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06723600208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7727704Medicaid