Provider Demographics
NPI:1750304762
Name:NIVALA, RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:NIVALA
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 1:5623 E DUNBAR RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48161-9127
Mailing Address - Country:US
Mailing Address - Phone:734-241-3891
Mailing Address - Fax:734-241-0014
Practice Address - Street 1:5623 E DUNBAR RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-9127
Practice Address - Country:US
Practice Address - Phone:734-241-3891
Practice Address - Fax:734-241-0014
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301027018207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI105191943Medicaid
MIP00606310OtherRAILROAD MEDICARE - INDIV
MICA3050OtherRAILROAD MEDICARE - GROUP
MIRN027018OtherINITIALS AND LIC #
MIRN027018OtherINITIALS AND LIC #