Healthcare Provider Details

I. General information

NPI: 1073581971
Provider Name (Legal Business Name): MARIA LOURDES P RIVERA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

144 NORTH CT
DIXON IL
61021
US

IV. Provider business mailing address

102 S HENNEPIN AVE
DIXON IL
61021-3083
US

V. Phone/Fax

Practice location:
  • Phone: 815-285-5437
  • Fax: 815-285-8928
Mailing address:
  • Phone: 815-288-7711
  • Fax: 815-285-8902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-092336
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: