Healthcare Provider Details

I. General information

NPI: 1023625167
Provider Name (Legal Business Name): MARIA J RIVERA OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2020
Last Update Date: 09/23/2020
Certification Date: 09/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 S UTICA AVE
TULSA OK
74104-2641
US

IV. Provider business mailing address

2221 E BIJOU ST STE 100
COLORADO SPRINGS CO
80909-8009
US

V. Phone/Fax

Practice location:
  • Phone: 918-585-3744
  • Fax: 918-535-3774
Mailing address:
  • Phone: 719-576-1850
  • Fax: 719-955-3470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3096
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: