Provider Demographics
NPI:1356671994
Name:NIETO, MARIO EDMUNDO (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:EDMUNDO
Last Name:NIETO
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 840853
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-1019
Mailing Address - Country:US
Mailing Address - Phone:972-233-1999
Mailing Address - Fax:972-233-3666
Practice Address - Street 1:3705 MEDICAL PKWY
Practice Address - Street 2:SUITE 570
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1019
Practice Address - Country:US
Practice Address - Phone:512-454-2554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-04
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP2905207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology