Healthcare Provider Details

I. General information

NPI: 1295838167
Provider Name (Legal Business Name): EVELYN CUARESMA RIVERO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4352 FOUNTAIN AVENUE
L A CA
90029
US

IV. Provider business mailing address

4352 FOUNTAIN AVENUE
L A CA
90029
US

V. Phone/Fax

Practice location:
  • Phone: 323-913-9094
  • Fax: 323-913-2492
Mailing address:
  • Phone: 323-913-9094
  • Fax: 323-913-2492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA37002
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: