Provider Demographics
NPI:1407046766
Name:RIVERA, MELANIO AYHON (IDC)
Entity Type:Individual
Prefix:MR
First Name:MELANIO
Middle Name:AYHON
Last Name:RIVERA
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 MARINE DR
Mailing Address - Street 2:
Mailing Address - City:N TOPSAIL BEACH
Mailing Address - State:NC
Mailing Address - Zip Code:28460-6778
Mailing Address - Country:US
Mailing Address - Phone:910-327-0636
Mailing Address - Fax:
Practice Address - Street 1:CG II MEF
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542
Practice Address - Country:US
Practice Address - Phone:910-451-0451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-01
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman