Provider Demographics
NPI:1407966591
Name:GUEVARA-NIETO, JESUS DAVID (MD)
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:DAVID
Last Name:GUEVARA-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 1:330 TURNER MCCALL BLVD SW
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-5630
Mailing Address - Country:US
Mailing Address - Phone:706-509-4340
Mailing Address - Fax:706-291-2147
Practice Address - Street 1:330 TURNER MCCALL BLVD SW
Practice Address - Street 2:SUITE 201
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-5630
Practice Address - Country:US
Practice Address - Phone:706-509-4340
Practice Address - Fax:706-291-2147
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2017-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051942207R00000X
MDD68405208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA636426670AMedicaid
GA636426670AMedicaid
11SCDHGMedicare ID - Type Unspecified