Provider Demographics
NPI:1720083702
Name:LARRIVEY, ROBERTO A (MD)
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:A
Last Name:LARRIVEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5555 PEACHTREE DUNWOODY RD NE
Mailing Address - Street 2:STE 125
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1703
Mailing Address - Country:US
Mailing Address - Phone:404-255-2918
Mailing Address - Fax:404-255-5837
Practice Address - Street 1:790 CHURCH ST NE
Practice Address - Street 2:STE 140
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-8902
Practice Address - Country:US
Practice Address - Phone:770-425-7199
Practice Address - Fax:678-819-5538
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052983207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA956323850AMedicaid
GA956323850BMedicaid
GA04BDCLXMedicare ID - Type Unspecified
GAC65598Medicare UPIN