Provider Demographics
NPI:1942261052
Name:RIVAS, CARLOS A (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:A
Last Name:RIVAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CARLOS
Other - Middle Name:A
Other - Last Name:RIVAS RAMIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3065 WILLIAM ST
Mailing Address - Street 2:SUITE 209
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-6393
Mailing Address - Country:US
Mailing Address - Phone:573-335-4100
Mailing Address - Fax:573-339-7887
Practice Address - Street 1:3065 WILLIAM ST
Practice Address - Street 2:SUITE 209
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-6393
Practice Address - Country:US
Practice Address - Phone:573-335-4100
Practice Address - Fax:573-339-7887
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-29
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR4668208D00000X
MO2010011993208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1942261052Medicaid
MA4167003Medicare PIN
G40436Medicare UPIN