MEDICARE: DR. AXEL E. RIVERA O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	46	VI
2	152W00000X	Optometrist	308	PR
3	152W00000X	Optometrist	4901004622	MI

General Provider Information

NPI Number	:	1457477200
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AXEL E. RIVERA O.D.

Provider Business Mailing Address
First Line	:	118 CASS AVE
Second Line	:
City	:	MOUNT CLEMENS
State	:	MI
Zip	:	48043-2204
Country	:	US
Telephone Number	:	586-468-7370
Fax Number	:

Provider Business Practice Location Address
First Line	:	10791 BELLEVILLE RD
Second Line	:
City	:	VAN BUREN TWP
State	:	MI
Zip	:	48111-1097
Country	:	US
Telephone Number	:	734-391-3080
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2007
Last Update Date	:	10/07/2019

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