Healthcare Provider Details

I. General information

NPI: 1134533961
Provider Name (Legal Business Name): LUCERO JACQUELINE VIVAR M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2014
Last Update Date: 08/08/2024
Certification Date: 08/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11351 E S FRONTAGE ROAD
YUMA AZ
85367
US

IV. Provider business mailing address

PO BOX 6298
AIKEN SC
29804-6298
US

V. Phone/Fax

Practice location:
  • Phone: 928-336-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number78471
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number73781
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: