Healthcare Provider Details

I. General information

NPI: 1124149653
Provider Name (Legal Business Name): TIMOTHY B RILEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 11/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4045 3RD AVE SUITE 301
SAN DIEGO CA
92103-2132
US

IV. Provider business mailing address

4045 3RD AVE SUITE 301
SAN DIEGO CA
92103-2132
US

V. Phone/Fax

Practice location:
  • Phone: 619-297-4901
  • Fax: 619-688-5993
Mailing address:
  • Phone: 619-297-4901
  • Fax: 619-688-5993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberG33037
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberG33037
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License NumberG33037
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: