Healthcare Provider Details

I. General information

NPI: 1235529140
Provider Name (Legal Business Name): DELARIVA MD PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2015
Last Update Date: 01/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3477 CASTLE CREEK CT
ROSEVILLE CA
95661-7354
US

IV. Provider business mailing address

PO BOX 441
SUISUN CITY CA
94585-0441
US

V. Phone/Fax

Practice location:
  • Phone: 916-778-6311
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: JUAN DE LA RIVA
Title or Position: PRESIDENT
Credential:
Phone: 916-778-6311