1174507743 NPI number — MARY H. RIVERO-HOMER MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174507743 NPI number — MARY H. RIVERO-HOMER MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

RIVERO-HOMER

Provider First Name:

MARY

Provider Middle Name:

H.

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

F

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:

1174507743

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

11/21/2012

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 660599

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

DALLAS

Provider Business Mailing Address State Name:

TX

Provider Business Mailing Address Postal Code:

75266-0599

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

1400 N WESTMORELAND RD

Provider Second Line Business Practice Location Address:

DEHARO-SALDIVAR HEALTH CENTER

Provider Business Practice Location Address City Name:

DALLAS

Provider Business Practice Location Address State Name:

TX

Provider Business Practice Location Address Postal Code:

75211-1656

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

214-266-0565

Provider Business Practice Location Address Fax Number:

214-266-0578

Provider Enumeration Date:

12/06/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207R00000X , with the licence number:  J3376 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 139122908 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 139122914 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 139122909 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 139122901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 139122911 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 139122912 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 139122902 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 139122906 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 139122907 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 139122903 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 139122904 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 139122905 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 139122910 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 86Z762 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".