Provider Demographics
NPI:1851854731
Name:RIEVESCHL, NATHANIEL B
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:B
Last Name:RIEVESCHL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12885 SW 1ST LN APT 410
Mailing Address - Street 2:
Mailing Address - City:NEWBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32669-3587
Mailing Address - Country:US
Mailing Address - Phone:504-214-2722
Mailing Address - Fax:
Practice Address - Street 1:1886 S 14TH ST STE 5
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-4719
Practice Address - Country:US
Practice Address - Phone:504-214-2722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-09
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME161961207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program