Provider Demographics
NPI:1053360214
Name:RIVERA, REGINA P (MD)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:P
Last Name:RIVERA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3906 BOWSER AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-3701
Mailing Address - Country:US
Mailing Address - Phone:214-599-8729
Mailing Address - Fax:
Practice Address - Street 1:115 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:SULPHUR SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:75482-2105
Practice Address - Country:US
Practice Address - Phone:903-885-7671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005002608207P00000X
TXM3713207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX184231202Medicaid
TX184231208Medicaid
TX1H0243OtherMEDICARE
TX184231201Medicaid
TX8V2874OtherBCBS
TX184231209Medicaid
TXP00373324OtherRAILROAD