Provider Demographics
NPI:1366511552
Name:RIVERA, ROSTOM DANO (MD)
Entity type:Individual
Prefix:
First Name:ROSTOM
Middle Name:DANO
Last Name:RIVERA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7808 PACIFIC AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98408-7039
Mailing Address - Country:US
Mailing Address - Phone:253-474-3329
Mailing Address - Fax:
Practice Address - Street 1:7808 PACIFIC AVE STE 4
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98408-7039
Practice Address - Country:US
Practice Address - Phone:253-474-3329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00010356207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA12776OtherL&I
WARI2850OtherREGENCE
WA1031608Medicaid
WAAETNAOtherAETNA
WARI2850OtherREGENCE
WAA08589Medicare UPIN