Provider Demographics
NPI:1982972063
Name:RIVERA, ANGEL KEITH (OD)
Entity Type:Individual
Prefix:DR
First Name:ANGEL
Middle Name:KEITH
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:PO BOX 1701
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-7001
Mailing Address - Country:US
Mailing Address - Phone:787-510-5403
Mailing Address - Fax:
Practice Address - Street 1:1310 PREACHER ROE BLVD # HGW
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-2938
Practice Address - Country:US
Practice Address - Phone:787-510-5403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011037045152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist