Provider Demographics
NPI:1538354717
Name:RIVAS, ADRIAN (IDC)
Entity type:Individual
Prefix:
First Name:ADRIAN
Middle Name:
Last Name:RIVAS
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 GATOR BLVD
Mailing Address - Street 2:BUILDING 3808
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23521-2902
Mailing Address - Country:US
Mailing Address - Phone:757-462-1056
Mailing Address - Fax:757-462-3111
Practice Address - Street 1:1900 GATOR BLVD
Practice Address - Street 2:BUILDING 3808
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23521-2902
Practice Address - Country:US
Practice Address - Phone:757-462-1056
Practice Address - Fax:757-462-3111
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-11
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman