Healthcare Provider Details

I. General information

NPI: 1891842365
Provider Name (Legal Business Name): DOUGLAS CHARLES RIVARD D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 GILLHAM RD.
KANSAS CITY MO
64108
US

IV. Provider business mailing address

2401 GILLHAM RD.
KANSAS CITY MO
64108
US

V. Phone/Fax

Practice location:
  • Phone: 816-234-3273
  • Fax: 816-983-6912
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number2006014609
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: