Provider Demographics
NPI:1164912507
Name:RIVERA, DANIEL (DO)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:RIVERA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 190930
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-0930
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:
Practice Address - Street 1:999 N CURTIS RD STE 415
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1334
Practice Address - Country:US
Practice Address - Phone:208-302-2600
Practice Address - Fax:208-302-2625
Is Sole Proprietor?:No
Enumeration Date:2018-05-11
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101023796208600000X
IDO-2014208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery