Healthcare Provider Details

I. General information

NPI: 1548248099
Provider Name (Legal Business Name): RICARDO C RIVERON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 11/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2241 ROMBACH RD.
WILMINGTON OH
45177
US

IV. Provider business mailing address

122 E COLLEGE AVE
APPLETON WI
54911-5741
US

V. Phone/Fax

Practice location:
  • Phone: 937-383-1040
  • Fax: 937-383-1380
Mailing address:
  • Phone: 920-996-3264
  • Fax: 920-830-5910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number35053423
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number68765
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: