Provider Demographics
NPI:1275631236
Name:REYES, ELIZABETH RIVERA (MD)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:RIVERA
Last Name:REYES
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 1:301 W BASTANCHURY RD STE 115
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-3423
Mailing Address - Country:US
Mailing Address - Phone:714-446-9030
Mailing Address - Fax:714-446-9130
Practice Address - Street 1:301 W BASTANCHURY RD STE 115
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-3423
Practice Address - Country:US
Practice Address - Phone:714-446-9030
Practice Address - Fax:714-446-9130
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67305208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8688134Medicaid
CA9668134Medicaid