Provider Demographics
NPI:1073587788
Name:NILES, CHAD R (MD)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:R
Last Name:NILES
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:PO BOX 847522
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-7522
Mailing Address - Country:US
Mailing Address - Phone:903-531-5000
Mailing Address - Fax:
Practice Address - Street 1:2026 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766-5822
Practice Address - Country:US
Practice Address - Phone:903-541-4500
Practice Address - Fax:903-541-0791
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL08822085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX044936507Medicaid
TX8V5498OtherBCBS TC RADIOLOGY
H22266Medicare UPIN
TX044936507Medicaid