Provider Demographics
NPI:1639673387
Name:RIVERS, DUSTIN RYAN (MD)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:RYAN
Last Name:RIVERS
Suffix:
Gender:M
Credentials:MD
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 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-9235
Mailing Address - Fax:239-343-4008
Practice Address - Street 1:12600 CREEKSIDE LN STE 2
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-3353
Practice Address - Country:US
Practice Address - Phone:239-343-9235
Practice Address - Fax:239-343-4008
Is Sole Proprietor?:No
Enumeration Date:2018-03-19
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1549232084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114418100Medicaid