Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | 01074619A | CA |
N | 111NI0900X | Internist | 01074619A | CA |
N | 207R00000X | Internist | M7729 | TX |
N | 111NI0900X | Internist | M7729 | TX |
Y | 207RA0001X | Advanced Heart Failure and Transplant Cardiologist | 01074619A | IN |
N | 207RC0000X | Internist - Cardiovascular Disease | 01074619A | CA |
N | 207RC0000X | Internist - Cardiovascular Disease | 01074619A | IN |
N | 207RC0000X | Internist - Cardiovascular Disease | A110940 | CA |
NPI | 1932399508 |
---|---|
Provider Name | Rey Percival Duarte Vivo |
First Address | Indianapolis, IN 46250-2890 |
Second Address | Indianapolis, IN 46219-3052 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/07/2007 |
Last Update Date | 14/06/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
188693904 | (05) | TX |
201254420 | (05) | IN |
8AH679 | BLUE CROSS BLUE SHIELD (01) | TX |
P01424406 | MEDICARE RAILROAD PTAN (01) | IN |