Provider Demographics
NPI:1295785186
Name:RIVERA, ANTONIO (MD)
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:RIVERA
Suffix:
Gender:
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 42532
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85733-2532
Mailing Address - Country:US
Mailing Address - Phone:928-919-2815
Mailing Address - Fax:
Practice Address - Street 1:1 INDIAN HILL ROAD
Practice Address - Street 2:
Practice Address - City:WINTERHAVEN
Practice Address - State:CA
Practice Address - Zip Code:92283
Practice Address - Country:US
Practice Address - Phone:760-572-4115
Practice Address - Fax:760-572-2133
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301079091207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ733255Medicaid
AZF18920Medicare UPIN
AZ8HAX06Medicare ID - Type Unspecified