Provider Demographics
NPI:1629403191
Name:CHIONG-RIVERO, HORACIO (MD, PHD)
Entity Type:Individual
Prefix:
First Name:HORACIO
Middle Name:
Last Name:CHIONG-RIVERO
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:HORACIO
Other - Middle Name:
Other - Last Name:CHIONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD, PHD
Mailing Address - Street 1:600 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2410
Mailing Address - Country:US
Mailing Address - Phone:817-882-2512
Mailing Address - Fax:
Practice Address - Street 1:1500 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4917
Practice Address - Country:US
Practice Address - Phone:817-702-3100
Practice Address - Fax:817-927-3603
Is Sole Proprietor?:No
Enumeration Date:2013-09-03
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1612102084N0400X
MA2640672084N0400X
TXS46112084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA264067OtherMASSACHUSETTS LICENSING BOARD