Provider Demographics
NPI:1407012578
Name:ROSTOM D RIVERA, MD
Entity Type:Organization
Organization Name:ROSTOM D RIVERA, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ROSTOM
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-474-3329
Mailing Address - Street 1:7800 PACIFIC AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98408-7050
Mailing Address - Country:US
Mailing Address - Phone:253-474-3329
Mailing Address - Fax:
Practice Address - Street 1:7800 PACIFIC AVE STE 4
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98408-7050
Practice Address - Country:US
Practice Address - Phone:253-474-3329
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-29
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
001001012Medicare PIN