Healthcare Provider Details

I. General information

NPI: 1831504828
Provider Name (Legal Business Name): MARIO RIVERA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2014
Last Update Date: 06/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3369 BUFORD HWY NE SUITE 810
ATLANTA GA
30329-3722
US

IV. Provider business mailing address

3369 BUFORD HWY NE SUITE 810
ATLANTA GA
30329-3722
US

V. Phone/Fax

Practice location:
  • Phone: 404-321-4692
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number27722
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: