Provider Demographics
NPI:1942311311
Name:RIVERA, MARCELO R (MD)
Entity Type:Individual
Prefix:DR
First Name:MARCELO
Middle Name:R
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 1:15644 POMERADO RD
Mailing Address - Street 2:#300
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-2400
Mailing Address - Country:US
Mailing Address - Phone:858-613-8743
Mailing Address - Fax:858-613-9274
Practice Address - Street 1:15644 POMERADO RD
Practice Address - Street 2:#300
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2400
Practice Address - Country:US
Practice Address - Phone:858-613-8743
Practice Address - Fax:858-613-9274
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG39240174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG39240Medicare PIN
CAA47749Medicare UPIN