Provider Demographics
NPI:1578876736
Name:AGOSTO-RIVERA, MARIELA
Entity Type:Individual
Prefix:
First Name:MARIELA
Middle Name:
Last Name:AGOSTO-RIVERA
Suffix:
Gender:F
Credentials:
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 1198
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79604-1198
Mailing Address - Country:US
Mailing Address - Phone:325-670-4220
Mailing Address - Fax:325-670-4040
Practice Address - Street 1:1749 PINE ST
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79601-3043
Practice Address - Country:US
Practice Address - Phone:325-670-6290
Practice Address - Fax:325-670-6289
Is Sole Proprietor?:No
Enumeration Date:2010-07-16
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXP6561207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program