Provider Demographics
NPI:1770637761
Name:RIVERA, RODULFO LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:RODULFO
Middle Name:LEE
Last Name:RIVERA
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 1:8032 CAVALIER DR
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-7261
Mailing Address - Country:US
Mailing Address - Phone:214-535-7787
Mailing Address - Fax:
Practice Address - Street 1:663 JUSTIN RD
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-4821
Practice Address - Country:US
Practice Address - Phone:972-772-0007
Practice Address - Fax:214-771-0780
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE6894208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC21103Medicare UPIN