Provider Demographics
NPI:1104131242
Name:JOSE L. RIVAS, M.D., A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:JOSE L. RIVAS, M.D., A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:L
Authorized Official - Last Name:RIVAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-583-6361
Mailing Address - Street 1:3100 E FLORENCE AVE
Mailing Address - Street 2:SUITE 7
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-5848
Mailing Address - Country:US
Mailing Address - Phone:323-583-6361
Mailing Address - Fax:323-583-2923
Practice Address - Street 1:3100 E FLORENCE AVE
Practice Address - Street 2:SUITE 7
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-5848
Practice Address - Country:US
Practice Address - Phone:323-583-6361
Practice Address - Fax:323-583-2923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-13
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33853174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A338530Medicaid
CAB50238Medicare PIN
CA1801897681Medicare UPIN