Healthcare Provider Details

I. General information

NPI: 1932817194
Provider Name (Legal Business Name): MARC FRANZ RIVERA DEDIOS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2022
Last Update Date: 06/24/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35000 GUADALCANAL ST
SAN DIEGO CA
92140-5599
US

IV. Provider business mailing address

ATTN: MEDICAL STAFF SERVICES 34800 BOB WILSON DRIVE
SAN DIEGO CA
92134
US

V. Phone/Fax

Practice location:
  • Phone: 619-524-4045
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2471C3401X
TaxonomyComputed Tomography Radiologic Technologist
License Number535689
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License Number535689
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: