Provider Demographics
NPI:1790411379
Name:RIVERA, DANIEL SIXTO
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:SIXTO
Last Name:RIVERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:995 GATEWAY CENTER WAY STE 106
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4544
Mailing Address - Country:US
Mailing Address - Phone:619-772-2579
Mailing Address - Fax:619-717-8863
Practice Address - Street 1:995 GATEWAY CENTER WAY STE 106
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-4544
Practice Address - Country:US
Practice Address - Phone:619-772-2579
Practice Address - Fax:619-717-8863
Is Sole Proprietor?:No
Enumeration Date:2022-07-27
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3704Medicaid