Provider Demographics
NPI:1477916260
Name:RIVAS, ESTEVAN
Entity Type:Individual
Prefix:
First Name:ESTEVAN
Middle Name:
Last Name:RIVAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15611 NEWKIRK RD
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79928-9046
Mailing Address - Country:US
Mailing Address - Phone:915-252-6173
Mailing Address - Fax:
Practice Address - Street 1:1660 COLUMBIA RD NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20009-3602
Practice Address - Country:US
Practice Address - Phone:202-469-4699
Practice Address - Fax:202-548-8600
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-30
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
DCDO034859207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program