Provider Demographics
NPI:1710522479
Name:RIVERA, MIKEL
Entity Type:Individual
Prefix:
First Name:MIKEL
Middle Name:
Last Name:RIVERA
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 1:1014 N ROSS AVE
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75090-4226
Mailing Address - Country:US
Mailing Address - Phone:903-819-8517
Mailing Address - Fax:
Practice Address - Street 1:314 N WALNUT ST STE C
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75090-0047
Practice Address - Country:US
Practice Address - Phone:903-771-0006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-16
Last Update Date:2019-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician