Provider Demographics
NPI:1780045682
Name:RIVERA, MARK JEFFERSON (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JEFFERSON
Last Name:RIVERA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MARK
Other - Middle Name:JEFFERSON
Other - Last Name:RIVERA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:269 S BEVERLY DR
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212-3851
Mailing Address - Country:US
Mailing Address - Phone:323-685-8130
Mailing Address - Fax:310-695-2797
Practice Address - Street 1:9735 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212-2107
Practice Address - Country:US
Practice Address - Phone:661-251-6300
Practice Address - Fax:661-443-8424
Is Sole Proprietor?:No
Enumeration Date:2016-03-19
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1578722086S0122X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery