Healthcare Provider Details

I. General information

NPI: 1336346972
Provider Name (Legal Business Name): TANIA LORENA RIVERA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TANIA L RIVERA VIDAL M.D.

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 S HICKORY ST SUITE 114
ESCONDIDO CA
92025-4359
US

IV. Provider business mailing address

8895 TOWNE CENTRE DR SUITE 105 #377
SAN DIEGO CA
92122-5542
US

V. Phone/Fax

Practice location:
  • Phone: 858-336-2810
  • Fax: 949-798-7990
Mailing address:
  • Phone: 858-336-2810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number265348
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number25MA09188500
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberA126958
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: