Provider Demographics
NPI:1083642037
Name:RIVERA, MANUEL (MD)
Entity Type:Individual
Prefix:
First Name:MANUEL
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:PO BOX 9520
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79995-9520
Mailing Address - Country:US
Mailing Address - Phone:915-545-9795
Mailing Address - Fax:915-545-9799
Practice Address - Street 1:4801 ALBERTA AVE.
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905
Practice Address - Country:US
Practice Address - Phone:915-545-6647
Practice Address - Fax:915-545-9799
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE7496207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX124209103Medicaid
TXPH0009OtherPTAN
TX89V442Medicare PIN
TX89C126Medicare ID - Type Unspecified
TXB56078Medicare UPIN