Provider Demographics
NPI:1225190002
Name:NIETO, JOSE M (DO)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:M
Last Name:NIETO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 SUN N LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33872-1986
Mailing Address - Country:US
Mailing Address - Phone:863-402-3103
Mailing Address - Fax:
Practice Address - Street 1:4200 SUN N LAKE BLVD
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33872-1986
Practice Address - Country:US
Practice Address - Phone:863-402-3103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8097207RG0100X
FLOS10072207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL279200100Medicaid
FL16365OtherBCBS FL
FL279200100Medicaid
FL16365OtherBCBS FL