Provider Demographics
NPI:1417389461
Name:RIVARD, MICHAEL A (IDC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:RIVARD
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 1:1711 DOOLITTLE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76127-1133
Mailing Address - Country:US
Mailing Address - Phone:817-782-5909
Mailing Address - Fax:817-782-5949
Practice Address - Street 1:1711 DOOLITTLE AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76127-1133
Practice Address - Country:US
Practice Address - Phone:817-782-5909
Practice Address - Fax:817-782-5949
Is Sole Proprietor?:No
Enumeration Date:2013-08-01
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman