Healthcare Provider Details

I. General information

NPI: 1275513897
Provider Name (Legal Business Name): JAYNE RIVAS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 W 11TH ST SMITH 834
NEW YORK NY
10011-8305
US

IV. Provider business mailing address

PO BOX 5070 GENERAL PO
NEW YORK NY
10087-0001
US

V. Phone/Fax

Practice location:
  • Phone: 212-604-7879
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number120423
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: