Healthcare Provider Details

I. General information

NPI: 1689935355
Provider Name (Legal Business Name): ADAM RIVADENEYRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 S MAIN ST STE 200
ORANGE CA
92868-3852
US

IV. Provider business mailing address

280 S MAIN ST STE 200
ORANGE CA
92868-3852
US

V. Phone/Fax

Practice location:
  • Phone: 714-634-4567
  • Fax:
Mailing address:
  • Phone: 714-634-4567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA132857
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA132857
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberA132857
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: