Provider Demographics
NPI:1093741159
Name:RIVAS, MANUEL A (MD)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:A
Last Name:RIVAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2081 KLOCKNER RD
Mailing Address - Street 2:BLDG 3 STE 16
Mailing Address - City:TRENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08690-3415
Mailing Address - Country:US
Mailing Address - Phone:609-588-5656
Mailing Address - Fax:609-588-9563
Practice Address - Street 1:2081 KLOCKNER RD
Practice Address - Street 2:BLDG 3 STE 16
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08690-3415
Practice Address - Country:US
Practice Address - Phone:609-588-5656
Practice Address - Fax:609-588-9563
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA02827200208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2910101Medicaid
NJD18618Medicare UPIN