Healthcare Provider Details

I. General information

NPI: 1144601816
Provider Name (Legal Business Name): MANUEL G RIVERA MAZA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2015
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 W UNIVERSITY AVE STE 300
MUNCIE IN
47303-3432
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 765-289-5420
  • Fax: 765-281-2065
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2019016629
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number01089549A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number01089549A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01089549A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: