Provider Demographics
NPI:1457477200
Name:RIVERA, AXEL E (OD)
Entity Type:Individual
Prefix:DR
First Name:AXEL
Middle Name:E
Last Name:RIVERA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 CASS AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-2204
Mailing Address - Country:US
Mailing Address - Phone:586-468-7370
Mailing Address - Fax:
Practice Address - Street 1:10791 BELLEVILLE RD
Practice Address - Street 2:
Practice Address - City:VAN BUREN TWP
Practice Address - State:MI
Practice Address - Zip Code:48111-1097
Practice Address - Country:US
Practice Address - Phone:734-391-3080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VI46152W00000X
PR308152W00000X
MI4901004622152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist