Healthcare Provider Details

I. General information

NPI: 1083951560
Provider Name (Legal Business Name): UNDA-RIVERA MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2013
Last Update Date: 01/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

907 E REED ST
HAYTI MO
63851-1242
US

IV. Provider business mailing address

105 RUSSELL ST P. O. BOX 393
HAYTI MO
63851-1300
US

V. Phone/Fax

Practice location:
  • Phone: 573-359-3660
  • Fax: 573-359-3521
Mailing address:
  • Phone: 573-359-2930
  • Fax: 573-359-1304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2011024431
License Number StateMO

VIII. Authorized Official

Name: DR. RAFAEL FRANCISCO UNDA-RIVERA
Title or Position: OWNER
Credential: MD
Phone: 573-359-3660