Basic Information
| Provider Information | |||||||||
| NPI: | 1831186279 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RIVERA | ||||||||
| FirstName: | ENRIQUE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 850001 | ||||||||
| Address2: | DEPT 217 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328850217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9413451950 | ||||||||
| FaxNumber: | 9413451951 | ||||||||
| Practice Location | |||||||||
| Address1: | 4351 CORTEZ RD W STE 200 | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342103140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417522840 | ||||||||
| FaxNumber: | 9417942808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2005 | ||||||||
| LastUpdateDate: | 08/31/2018 | ||||||||
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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 | 207RC0000X | ME79810 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | ME79810 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 260550300 | 05 | FL | MEDICAID | 58025 | 01 | FL | BCBS | OTHER |