Provider Demographics
NPI:1235622333
Name:RIVERA, MELANIE EDITH (IDMT)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:EDITH
Last Name:RIVERA
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4803 HAMILTON WOLFE RD APT 120
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-4338
Mailing Address - Country:US
Mailing Address - Phone:210-833-9353
Mailing Address - Fax:
Practice Address - Street 1:3600 ROGER BROOKE DRIVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78234
Practice Address - Country:US
Practice Address - Phone:210-916-9900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-13
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians