Provider Demographics
NPI:1306847116
Name:NIETO, ROBERTA (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERTA
Middle Name:
Last Name:NIETO
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 1:2811 E KATELLA AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92867-5247
Mailing Address - Country:US
Mailing Address - Phone:714-942-2643
Mailing Address - Fax:714-352-4194
Practice Address - Street 1:2811 E KATELLA AVE STE 203
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92867-5247
Practice Address - Country:US
Practice Address - Phone:714-942-2643
Practice Address - Fax:714-352-4194
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79361207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
BN8017483OtherDEA #
H96228Medicare UPIN