Basic Information
| Provider Information | |||||||||
| NPI: | 1083642037 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RIVERA | ||||||||
| FirstName: | MANUEL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9520 | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799959520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155459795 | ||||||||
| FaxNumber: | 9155459799 | ||||||||
| Practice Location | |||||||||
| Address1: | 4801 ALBERTA AVE. | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 79905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155456647 | ||||||||
| FaxNumber: | 9155459799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 12/11/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | E7496 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | E7496 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 124209103 | 05 | TX | MEDICAID | PH0009 | 01 | TX | PTAN | OTHER |