Provider Demographics
NPI:1568493427
Name:RIVERON, FERNANDO A (MD)
Entity Type:Individual
Prefix:
First Name:FERNANDO
Middle Name:A
Last Name:RIVERON
Suffix:
Gender:M
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:PO BOX 190930
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-0930
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:6140 W CURTISIAN AVE STE 100
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-0109
Practice Address - Country:US
Practice Address - Phone:208-302-0130
Practice Address - Fax:208-302-0135
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60930244208G00000X
WI37552208G00000X
IDMC-0427208G00000X
IDM-15527208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32205400Medicaid
WA2127756Medicaid
39092Medicare ID - Type Unspecified