Provider Demographics
NPI:1083642359
Name:NIEVES, JENNIFER (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:NIEVES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 CALLE 1
Mailing Address - Street 2:PMB 109 BOX 70005
Mailing Address - City:FAJARDO
Mailing Address - State:PR
Mailing Address - Zip Code:00738-4849
Mailing Address - Country:US
Mailing Address - Phone:787-657-0102
Mailing Address - Fax:787-657-0102
Practice Address - Street 1:CARR. #3 KM 28.8
Practice Address - Street 2:BO CAROLA
Practice Address - City:RIO GRANDE
Practice Address - State:PR
Practice Address - Zip Code:00745
Practice Address - Country:US
Practice Address - Phone:787-657-0102
Practice Address - Fax:787-657-0102
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13336208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR20057Medicare ID - Type Unspecified
PRH60159Medicare UPIN