Healthcare Provider Details

I. General information

NPI: 1477916260
Provider Name (Legal Business Name): ESTEVAN RIVAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2016
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47923 OASIS ST
INDIO CA
92201-9203
US

IV. Provider business mailing address

15611 NEWKIRK RD
EL PASO TX
79928-9046
US

V. Phone/Fax

Practice location:
  • Phone: 760-863-8283
  • Fax:
Mailing address:
  • Phone: 915-252-6173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A22780
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO034859
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: