Provider Demographics
NPI:1811938087
Name:RIVERA, MARIA R (MD)
Entity type:Individual
Prefix:DR
First Name:MARIA
Middle Name:R
Last Name:RIVERA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 NW PECAN VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-9639
Mailing Address - Country:US
Mailing Address - Phone:580-536-2711
Mailing Address - Fax:
Practice Address - Street 1:4008 NW CACHE RD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-3634
Practice Address - Country:US
Practice Address - Phone:580-351-9949
Practice Address - Fax:580-351-9989
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK21818174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKH45878Medicare UPIN