Healthcare Provider Details

I. General information

NPI: 1275631236
Provider Name (Legal Business Name): ELIZABETH RIVERA REYES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 04/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 W BASTANCHURY RD STE 115
FULLERTON CA
92835-3423
US

IV. Provider business mailing address

301 W BASTANCHURY RD STE 115
FULLERTON CA
92835-3423
US

V. Phone/Fax

Practice location:
  • Phone: 714-446-9030
  • Fax: 714-446-9130
Mailing address:
  • Phone: 714-446-9030
  • Fax: 714-446-9130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA67305
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: