1679798342 NPI number — ANTONIO RIVERA

Table of content: ANTONIO RIVERA (NPI 1679798342)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679798342 NPI number — ANTONIO RIVERA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RIVERA
Provider First Name:
ANTONIO
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RIVERA
Provider Other First Name:
P ANTONIO
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHYSICIAN ASSISTANT
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1679798342
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2151 W 6TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90057-3121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
213-483-2222
Provider Business Mailing Address Fax Number:
213-483-6161

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2151 W 6TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90057-3121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-483-2222
Provider Business Practice Location Address Fax Number:
213-483-6161
Provider Enumeration Date:
04/16/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  13146 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)