Healthcare Provider Details

I. General information

NPI: 1053382895
Provider Name (Legal Business Name): LUIS RAUL RIVERO M.D., M.P.H.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 08/10/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

WEED ARMY COMMUNITY HOSPITAL 390 NORTH LOOP ROAD
FORT IRWIN CA
92310-1507
US

IV. Provider business mailing address

PO BOX 105109
FORT IRWIN CA
92310-5109
US

V. Phone/Fax

Practice location:
  • Phone: 760-383-5004
  • Fax:
Mailing address:
  • Phone: 760-383-5284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number12919
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number12919
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: