Basic Information
Provider Information | |||||||||
NPI: | 1184659195 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RIVERA | ||||||||
FirstName: | JOSE' | ||||||||
MiddleName: | F. | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 9247 | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | GA | ||||||||
PostalCode: | 319089247 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7063227884 | ||||||||
FaxNumber: | 7062434356 | ||||||||
Practice Location | |||||||||
Address1: | 610 19TH ST | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | GA | ||||||||
PostalCode: | 319011528 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7063227884 | ||||||||
FaxNumber: | 7066602143 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/11/2006 | ||||||||
LastUpdateDate: | 05/06/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN088485 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 417123182C | 05 | GA |   | MEDICAID | 165684204A | 05 | GA |   | MEDICAID |