Provider Demographics
NPI:1396721635
Name:PESAVENTO, RICHARD DOMINIC (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:DOMINIC
Last Name:PESAVENTO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9041 MAGNOLIA AVE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-3900
Mailing Address - Country:US
Mailing Address - Phone:951-788-0222
Mailing Address - Fax:951-784-2696
Practice Address - Street 1:9041 MAGNOLIA AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3900
Practice Address - Country:US
Practice Address - Phone:951-788-0222
Practice Address - Fax:951-784-2696
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2011-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG44858207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G448580Medicaid
CABV635YMedicare PIN
CA00G448580Medicare PIN
CAA49779Medicare UPIN