Provider Demographics
NPI:1891796660
Name:SOLIVAN, LUIS A (MD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:A
Last Name:SOLIVAN
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 15648
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95852-0648
Mailing Address - Country:US
Mailing Address - Phone:951-781-2270
Mailing Address - Fax:951-781-2293
Practice Address - Street 1:4445 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-4135
Practice Address - Country:US
Practice Address - Phone:951-788-3400
Practice Address - Fax:951-788-3194
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9500732085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA009500730Medicaid
CA00G500730Medicaid
CA00G500734Medicare PIN
E79715Medicare UPIN
CA00G500730Medicaid
CA009500730Medicaid
CA00G500730Medicare PIN
CA00G500731Medicare PIN
CA00G500735Medicare PIN