Provider Demographics
NPI:1427373265
Name:RIVKIN, MARK ANATOLY (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ANATOLY
Last Name:RIVKIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 955534
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-5534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1055 BOWLES AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2308
Practice Address - Country:US
Practice Address - Phone:636-496-3900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-05
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT012336207T00000X
MO2014038760207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery