Healthcare Provider Details

I. General information

NPI: 1366410276
Provider Name (Legal Business Name): EMILIO T. RIVERA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5290 MCNUTT RD STE 109
SANTA TERESA NM
88008
US

IV. Provider business mailing address

PO BOX 1590
SANTA TERESA NM
88008-1590
US

V. Phone/Fax

Practice location:
  • Phone: 575-589-1144
  • Fax: 575-589-2008
Mailing address:
  • Phone: 575-589-1144
  • Fax: 575-589-2008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number89-285
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number89-285
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: