Provider Demographics
NPI:1548248099
Name:RIVERON, RICARDO C (MD)
Entity type:Individual
Prefix:
First Name:RICARDO
Middle Name:C
Last Name:RIVERON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 E COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-5741
Mailing Address - Country:US
Mailing Address - Phone:920-996-3264
Mailing Address - Fax:920-830-5910
Practice Address - Street 1:2241 ROMBACH RD.
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177
Practice Address - Country:US
Practice Address - Phone:937-383-1040
Practice Address - Fax:937-383-1380
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35053423207P00000X
WI68765207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0624711Medicaid
OHRI4040399Medicare PIN
OHRI4040397Medicare PIN
OHA16429Medicare UPIN