Healthcare Provider Details

I. General information

NPI: 1629218235
Provider Name (Legal Business Name): ANGEL LUIS RIVERA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2009
Last Update Date: 03/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2740 W FOSTER AVE LL7
CHICAGO IL
60625-3500
US

IV. Provider business mailing address

5215 N CALIFORNIA AVE STE 603
CHICAGO IL
60625-7014
US

V. Phone/Fax

Practice location:
  • Phone: 773-878-8200
  • Fax: 773-293-4197
Mailing address:
  • Phone: 773-878-3627
  • Fax: 773-293-8824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036126911
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: