Healthcare Provider Details

I. General information

NPI: 1619905189
Provider Name (Legal Business Name): JON PERSICHINO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 04/14/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7117 BROCKTON AVE
RIVERSIDE CA
92506-2658
US

IV. Provider business mailing address

7117 BROCKTON AVE
RIVERSIDE CA
92506-2658
US

V. Phone/Fax

Practice location:
  • Phone: 951-782-3694
  • Fax: 951-784-3272
Mailing address:
  • Phone: 951-782-3694
  • Fax: 951-784-3272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number20A8923
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number20A8923
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: