=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366412363
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN DIANNE RIBEIRO M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2006
-----------------------------------------------------
Last Update Date | 01/31/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18653 WEDGE PARKWAY, SUITE 130
-----------------------------------------------------
City | RENO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-770-7630
-----------------------------------------------------
Fax | 775-770-7635
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18653 WEDGE PARKWAY, SUITE 130
-----------------------------------------------------
City | RENO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-770-7630
-----------------------------------------------------
Fax | 775-770-7635
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 9124
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------