Provider Demographics
NPI:1205490620
Name:RIVAS, JERRY
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:RIVAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3655 MIDVALE AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94602-3863
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:205 39TH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94805-2212
Practice Address - Country:US
Practice Address - Phone:510-412-5930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-01
Last Update Date:2023-08-08
Deactivation Date:2023-07-12
Deactivation Code:
Reactivation Date:2023-08-04
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program