1770159428 NPI number — CRYSTAL MARIA RIVERA PEREZ MD

Table of content: CRYSTAL MARIA RIVERA PEREZ MD (NPI 1770159428)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770159428 NPI number — CRYSTAL MARIA RIVERA PEREZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RIVERA PEREZ
Provider First Name:
CRYSTAL
Provider Middle Name:
MARIA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1770159428
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1230 BAXTER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATHENS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30606-3712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-389-3860
Provider Business Mailing Address Fax Number:
706-389-3861

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 OGLETHORPE AVE SUITE 200D
Provider Second Line Business Practice Location Address:
COMMUNITY INTERNAL MEDICINE OF ATHENS
Provider Business Practice Location Address City Name:
ATHENS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-389-3875
Provider Business Practice Location Address Fax Number:
706-389-3876
Provider Enumeration Date:
06/02/2021

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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