Provider Demographics
NPI:1104485648
Name:RIVES, GREGORY TYLER (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:TYLER
Last Name:RIVES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 S UNIVERSITY AVE APT 3303
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5239
Mailing Address - Country:US
Mailing Address - Phone:870-415-7990
Mailing Address - Fax:
Practice Address - Street 1:96 JONATHAN LUCAS ST CSB 423-A / MSC 613
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-0001
Practice Address - Country:US
Practice Address - Phone:843-792-3072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-09
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL82795208600000X
LA341799208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery