Healthcare Provider Details

I. General information

NPI: 1780648295
Provider Name (Legal Business Name): GUSTAVO ERNESTO RIOS MD, FAAP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 MEMORIAL DR
JACKSONVILLE NC
28546-6328
US

IV. Provider business mailing address

127 TWEED DR
JACKSONVILLE NC
28540-4591
US

V. Phone/Fax

Practice location:
  • Phone: 910-353-0581
  • Fax: 910-353-1351
Mailing address:
  • Phone: 910-687-0364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA07719500
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: