Healthcare Provider Details

I. General information

NPI: 1780830331
Provider Name (Legal Business Name): IAN MATTHEW RIVERA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2008
Last Update Date: 03/12/2026
Certification Date: 03/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W HOSPITAL RD
FORT GORDON GA
30905-5741
US

IV. Provider business mailing address

300 W HOSPITAL RD
FORT GORDON GA
30905-5741
US

V. Phone/Fax

Practice location:
  • Phone: 706-787-7665
  • Fax: 706-787-2326
Mailing address:
  • Phone: 706-787-7665
  • Fax: 706-787-2326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number61853
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number61853
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: