Provider Demographics
NPI:1174507743
Name:RIVERO-HOMER, MARY H (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:H
Last Name:RIVERO-HOMER
Suffix:
Gender:F
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 660599
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75266-0599
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 N WESTMORELAND RD
Practice Address - Street 2:DEHARO-SALDIVAR HEALTH CENTER
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75211-1656
Practice Address - Country:US
Practice Address - Phone:214-266-0565
Practice Address - Fax:214-266-0578
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3376207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX139122908Medicaid
TX139122914Medicaid
TX139122909Medicaid
TX139122901Medicaid
TX139122911Medicaid
TX139122912Medicaid
TX139122902Medicaid
TX139122906Medicaid
TX139122907Medicaid
TX139122903Medicaid
TX139122904Medicaid
TX139122905Medicaid
TX139122910Medicaid
TX86Z762OtherBLUE CROSS BLUE SHIELD
TX139122914Medicaid
TX139122902Medicaid