Provider Demographics
NPI:1205948783
Name:RIVAS, AGUSTIN (MD)
Entity type:Individual
Prefix:
First Name:AGUSTIN
Middle Name:
Last Name:RIVAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:AGUSTIN
Other - Middle Name:
Other - Last Name:RIVAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:175 W 49TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-3711
Mailing Address - Country:US
Mailing Address - Phone:786-621-9777
Mailing Address - Fax:786-621-9601
Practice Address - Street 1:6500 W 4TH AVE STE 13
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-6606
Practice Address - Country:US
Practice Address - Phone:786-621-9777
Practice Address - Fax:786-621-9601
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME100281174400000X, 208D00000X
FLME 100281208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No174400000XOther Service ProvidersSpecialist
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013332701Medicaid
FL013840000Medicaid
FL013840000Medicaid
F52632Medicare UPIN
AL17108OtherSTATE MEDICAL LICENSE