Provider Demographics
NPI:1932399300
Name:RIVAS, HOMERO II (MD)
Entity Type:Individual
Prefix:DR
First Name:HOMERO
Middle Name:
Last Name:RIVAS
Suffix:II
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 1:5617 HIGHWAY 153
Mailing Address - Street 2:SUITE 103
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-4675
Mailing Address - Country:US
Mailing Address - Phone:423-485-3226
Mailing Address - Fax:423-485-3302
Practice Address - Street 1:5617 HIGHWAY 153
Practice Address - Street 2:SUITE 103
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-4675
Practice Address - Country:US
Practice Address - Phone:423-485-3226
Practice Address - Fax:423-485-3302
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-31
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN42493208VP0014X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1506847Medicaid
TN4195338OtherBCBST
TN3002279Medicare PIN