Provider Demographics
NPI:1104984988
Name:RIVERA, DIEGO (MDPA)
Entity type:Individual
Prefix:DR
First Name:DIEGO
Middle Name:
Last Name:RIVERA
Suffix:
Gender:M
Credentials:MDPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79415-2844
Mailing Address - Country:US
Mailing Address - Phone:806-747-4415
Mailing Address - Fax:806-747-1304
Practice Address - Street 1:111 N UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79415-2844
Practice Address - Country:US
Practice Address - Phone:806-747-4415
Practice Address - Fax:806-747-1304
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG1757207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX123854505Medicaid
TX123854505Medicaid
TX8A1933Medicare PIN