Provider Demographics
NPI:1376547919
Name:RIVAS, HUMBERTO (MD)
Entity Type:Individual
Prefix:DR
First Name:HUMBERTO
Middle Name:
Last Name:RIVAS
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 1:1110 N SARAH DEWITT DR
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:TX
Mailing Address - Zip Code:78629-3311
Mailing Address - Country:US
Mailing Address - Phone:830-672-8502
Mailing Address - Fax:
Practice Address - Street 1:1110 N SARAH DEWITT DR
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:TX
Practice Address - Zip Code:78629-3311
Practice Address - Country:US
Practice Address - Phone:830-672-8473
Practice Address - Fax:830-672-3035
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX208000000X208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX130892609Medicaid
TXJ3202OtherSTATE LI
TX110010OtherMEDICARE
TXG01428Medicare UPIN