Provider Demographics
NPI:1114105780
Name:MARCELO R. RIVERA MD, INC.
Entity Type:Organization
Organization Name:MARCELO R. RIVERA MD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCELO
Authorized Official - Middle Name:R
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-613-8743
Mailing Address - Street 1:1516 MAIN ST
Mailing Address - Street 2:#104
Mailing Address - City:RAMONA
Mailing Address - State:CA
Mailing Address - Zip Code:92065-5242
Mailing Address - Country:US
Mailing Address - Phone:760-789-6044
Mailing Address - Fax:760-789-3852
Practice Address - Street 1:1516 MAIN ST
Practice Address - Street 2:#104
Practice Address - City:RAMONA
Practice Address - State:CA
Practice Address - Zip Code:92065-5242
Practice Address - Country:US
Practice Address - Phone:760-789-6044
Practice Address - Fax:760-789-3852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-06
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG39240174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAU7749Medicare UPIN
CA1643418Medicare PIN