MEDICARE: MARCELO R. RIVERA MD, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	G39240	CA

General Provider Information

NPI Number	:	1114105780
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARCELO R. RIVERA MD, INC.

Provider Business Mailing Address
First Line	:	1516 MAIN ST
Second Line	:	#104
City	:	RAMONA
State	:	CA
Zip	:	92065-5242
Country	:	US
Telephone Number	:	760-789-6044
Fax Number	:	760-789-3852

Provider Business Practice Location Address
First Line	:	1516 MAIN ST
Second Line	:	#104
City	:	RAMONA
State	:	CA
Zip	:	92065-5242
Country	:	US
Telephone Number	:	760-789-6044
Fax Number	:	760-789-3852

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MARCELO R RIVERA
Credential	:	M.D.
Telephone Number	:	858-613-8743

Provider Enumeration Date	:	02/06/2008
Last Update Date	:	02/06/2008

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