MEDICARE: MR. JUAN CARLOS RICAURTE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RI0200X	Infectious Disease Physician	A701690	CA
2	207RI0200X	Infectious Disease Physician	070169	CA

General Provider Information

NPI Number	:	1427046341
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JUAN CARLOS RICAURTE M.D.

Provider Business Mailing Address
First Line	:	1300 NORTH VERMONT AVE, SUITE 806
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90027-6302
Country	:	US
Telephone Number	:	323-663-6790
Fax Number	:	323-663-6791

Provider Business Practice Location Address
First Line	:	1300 NORTH VERMONT AVE, SUITE 806
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90027-6302
Country	:	US
Telephone Number	:	323-663-6790
Fax Number	:	323-663-6791

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/13/2005
Last Update Date	:	10/07/2014

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