Healthcare Provider Details

I. General information

NPI: 1821572249
Provider Name (Legal Business Name): JORDAN CRUZ RIVERA MD,MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2018
Last Update Date: 10/04/2022
Certification Date: 10/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1433 S ROBERTSON BLVD
LOS ANGELES CA
90035-3414
US

IV. Provider business mailing address

823 GATEWAY CENTER WAY
SAN DIEGO CA
92102-4541
US

V. Phone/Fax

Practice location:
  • Phone: 310-785-2121
  • Fax:
Mailing address:
  • Phone: 619-515-2300
  • 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 State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA166171
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: