Provider Demographics
NPI:1841442738
Name:ONTIVEROS, LUIS OMAR (MD)
Entity type:Individual
Prefix:DR
First Name:LUIS
Middle Name:OMAR
Last Name:ONTIVEROS
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 1:972 GOODRICH BLVD
Mailing Address - Street 2:
Mailing Address - City:COMMERCE
Mailing Address - State:CA
Mailing Address - Zip Code:90022-4114
Mailing Address - Country:US
Mailing Address - Phone:323-853-6060
Mailing Address - Fax:213-995-9894
Practice Address - Street 1:972 GOODRICH BLVD
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:CA
Practice Address - Zip Code:90022-4114
Practice Address - Country:US
Practice Address - Phone:323-853-6060
Practice Address - Fax:213-995-9894
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-22
Last Update Date:2020-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV13301207Q00000X
CAA101545207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1841442738Medicaid
NV1841442738Medicaid
NVCH785XMedicare PIN