Provider Demographics
NPI:1083951560
Name:UNDA-RIVERA MD LLC
Entity Type:Organization
Organization Name:UNDA-RIVERA MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:FRANCISCO
Authorized Official - Last Name:UNDA-RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-359-3660
Mailing Address - Street 1:105 RUSSELL ST
Mailing Address - Street 2:P. O. BOX 393
Mailing Address - City:HAYTI
Mailing Address - State:MO
Mailing Address - Zip Code:63851-1300
Mailing Address - Country:US
Mailing Address - Phone:573-359-2930
Mailing Address - Fax:573-359-1304
Practice Address - Street 1:907 E REED ST
Practice Address - Street 2:
Practice Address - City:HAYTI
Practice Address - State:MO
Practice Address - Zip Code:63851-1242
Practice Address - Country:US
Practice Address - Phone:573-359-3660
Practice Address - Fax:573-359-3521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-03
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011024431207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty