Provider Demographics
NPI:1073583274
Name:RIVERA, DOUGLAS JASON (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:JASON
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 1:2000 SCENIC DR STE G002
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-7726
Mailing Address - Country:US
Mailing Address - Phone:512-531-5200
Mailing Address - Fax:512-865-4068
Practice Address - Street 1:2000 SCENIC DR STE G002
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-7726
Practice Address - Country:US
Practice Address - Phone:512-531-5200
Practice Address - Fax:512-865-4068
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM20482085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX173387101Medicaid
TX27022YN57Medicare PIN
TX272022YN56Medicare PIN
TX173387101Medicaid