Provider Demographics
NPI:1891292629
Name:RIVERA, KENNY STEVEN (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNY
Middle Name:STEVEN
Last Name:RIVERA
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 737
Mailing Address - Street 2:
Mailing Address - City:SAN JOAQUIN
Mailing Address - State:CA
Mailing Address - Zip Code:93660-0737
Mailing Address - Country:US
Mailing Address - Phone:559-203-6640
Mailing Address - Fax:
Practice Address - Street 1:180 W SHAW AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-3746
Practice Address - Country:US
Practice Address - Phone:559-203-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-09
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA175093207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty