Provider Demographics
NPI:1053354092
Name:RIVAS-GOTZ, FEDERICO (MD)
Entity type:Individual
Prefix:
First Name:FEDERICO
Middle Name:
Last Name:RIVAS-GOTZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5514 CORPORATE DR STE 120
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64507-7754
Mailing Address - Country:US
Mailing Address - Phone:816-271-1350
Mailing Address - Fax:816-271-1355
Practice Address - Street 1:5514 CORPORATE DR STE 120
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64507-7754
Practice Address - Country:US
Practice Address - Phone:816-271-1350
Practice Address - Fax:816-271-1355
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002023849207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205998503Medicaid
KS200598670AMedicaid
MOP00752887OtherRAILROAD MEDICARE
MO701000022Medicare PIN
KS200598670AMedicaid