Healthcare Provider Details

I. General information

NPI: 1295785186
Provider Name (Legal Business Name): ANTONIO RIVERA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 03/21/2025
Certification Date: 03/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 INDIAN HILL ROAD
WINTERHAVEN CA
92283
US

IV. Provider business mailing address

PO BOX 42532
TUCSON AZ
85733-2532
US

V. Phone/Fax

Practice location:
  • Phone: 760-572-4115
  • Fax: 760-572-2133
Mailing address:
  • Phone: 928-919-2815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301079091
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: