Provider Demographics
NPI:1417728304
Name:PALOMINO RIVERA, ISIS DALIA
Entity Type:Individual
Prefix:
First Name:ISIS
Middle Name:DALIA
Last Name:PALOMINO RIVERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3216 S HARVEY AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73109-6325
Mailing Address - Country:US
Mailing Address - Phone:405-371-1636
Mailing Address - Fax:
Practice Address - Street 1:3216 S HARVEY AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-6325
Practice Address - Country:US
Practice Address - Phone:405-371-1636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty