Provider Demographics
NPI:1891087102
Name:RIVERA, ISMAEL OMAR (MD)
Entity Type:Individual
Prefix:MR
First Name:ISMAEL
Middle Name:OMAR
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 1:5015 S IH 35 STE 174
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:73301-2701
Mailing Address - Country:US
Mailing Address - Phone:512-804-3202
Mailing Address - Fax:
Practice Address - Street 1:100 W DEAN KEETON ST STOP A3900
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78712-1107
Practice Address - Country:US
Practice Address - Phone:512-804-3202
Practice Address - Fax:512-901-9717
Is Sole Proprietor?:No
Enumeration Date:2011-05-04
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10039553207Q00000X
TXQ1282207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine