Healthcare Provider Details

I. General information

NPI: 1962482968
Provider Name (Legal Business Name): JUAN ANTONIO RIVAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 11/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8380 BOYDTON PLANK ROAD
ALBERTA VA
23821
US

IV. Provider business mailing address

8380 BOYDTON PLANK ROAD
ALBERTA VA
23821
US

V. Phone/Fax

Practice location:
  • Phone: 434-949-7211
  • Fax: 434-949-7134
Mailing address:
  • Phone: 434-949-7211
  • Fax: 434-949-7134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101045047
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: