Provider Demographics
NPI:1073584793
Name:RIVERA, VICTOR (MD)
Entity Type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:
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 1:3535 S JEFFERSON AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63118-3930
Mailing Address - Country:US
Mailing Address - Phone:314-771-4600
Mailing Address - Fax:314-771-1701
Practice Address - Street 1:3535 S JEFFERSON AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63118-3930
Practice Address - Country:US
Practice Address - Phone:314-771-4600
Practice Address - Fax:314-771-1701
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR8843207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200997104Medicaid
MO2232Medicare ID - Type Unspecified
MOA24991Medicare UPIN