Provider Demographics
NPI:1891227674
Name:RIVERS, DIANA ALYCE (DO)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:ALYCE
Last Name:RIVERS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13880 BRADDOCK RD STE 301
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20121-2462
Mailing Address - Country:US
Mailing Address - Phone:703-222-2773
Mailing Address - Fax:
Practice Address - Street 1:13880 BRADDOCK RD STE 301
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121-2462
Practice Address - Country:US
Practice Address - Phone:703-222-2273
Practice Address - Fax:703-222-6093
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-30
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0102206745207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1891227674Medicaid