Provider Demographics
NPI:1790936771
Name:NIVA, ROGER A (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:A
Last Name:NIVA
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 1:2501 N 45TH ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-6909
Mailing Address - Country:US
Mailing Address - Phone:206-526-5222
Mailing Address - Fax:206-675-1460
Practice Address - Street 1:2501 N 45TH ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-6909
Practice Address - Country:US
Practice Address - Phone:206-526-5222
Practice Address - Fax:206-675-1460
Is Sole Proprietor?:No
Enumeration Date:2008-10-08
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WATD60045515207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology