1407849565 NPI number — MR. LUCIAN JOSEPH RIVELA MD

Table of content: MR. LUCIAN JOSEPH RIVELA MD (NPI 1407849565)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407849565 NPI number — MR. LUCIAN JOSEPH RIVELA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RIVELA
Provider First Name:
LUCIAN
Provider Middle Name:
JOSEPH
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407849565
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/16/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3007 WOODLAND HILLS DRIVE
Provider Second Line Business Mailing Address:
PMB 73
Provider Business Mailing Address City Name:
KINGWOOD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77339
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-354-1234
Provider Business Mailing Address Fax Number:
281-354-2514

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9191 PINECROFT DRIVE
Provider Second Line Business Practice Location Address:
STE 150
Provider Business Practice Location Address City Name:
THE WOODLANDS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77380
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-681-3905
Provider Business Practice Location Address Fax Number:
281-362-0403
Provider Enumeration Date:
08/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208200000X , with the licence number:  K4991 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 162775401 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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