Provider Demographics
NPI:1851575906
Name:DIEGO RIVERA, M.D., P.A.
Entity Type:Organization
Organization Name:DIEGO RIVERA, M.D., P.A.
Other - Org Name:UNIVERSITY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIEGO
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:806-747-4415
Mailing Address - Street 1:111 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79415
Mailing Address - Country:US
Mailing Address - Phone:806-747-4415
Mailing Address - Fax:806-747-1304
Practice Address - Street 1:111 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79415
Practice Address - Country:US
Practice Address - Phone:806-747-4415
Practice Address - Fax:806-747-1304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-26
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG1757207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX010066279OtherRAILROAD MEDICARE
TX158775001Medicaid
TX00495UMedicare PIN