Provider Demographics
NPI:1780830331
Name:RIVERA, IAN MATTHEW (MD)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:MATTHEW
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 1:300 E. HOSPITAL ROAD
Mailing Address - Street 2:ROOM 8A-30 (MCHF-M-NE)
Mailing Address - City:FORT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905
Mailing Address - Country:US
Mailing Address - Phone:706-787-7665
Mailing Address - Fax:706-787-2326
Practice Address - Street 1:300 E. HOSPITAL ROAD
Practice Address - Street 2:ROOM 8A-30 (MCHF-M-NE)
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905
Practice Address - Country:US
Practice Address - Phone:706-787-7665
Practice Address - Fax:706-787-2326
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-14
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA61853207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1780830331OtherNPI
VAD 000Medicare UPIN