Basic Information
| Provider Information | |||||||||
| NPI: | 1053360214 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RIVERA | ||||||||
| FirstName: | REGINA | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3906 BOWSER AVE | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752193701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2145998729 | ||||||||
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| Practice Location | |||||||||
| Address1: | 115 AIRPORT RD | ||||||||
| Address2: | |||||||||
| City: | SULPHUR SPRINGS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754822105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9038857671 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 01/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 2005002608 | MO | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | M3713 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 184231202 | 05 | TX | MEDICAID | 184231208 | 05 | TX | MEDICAID | 1H0243 | 01 | TX | MEDICARE | OTHER | 184231201 | 05 | TX | MEDICAID | 8V2874 | 01 | TX | BCBS | OTHER | 184231209 | 05 | TX | MEDICAID | P00373324 | 01 | TX | RAILROAD | OTHER |