Provider Demographics
NPI:1467169755
Name:NIEDO, MAX TO-VI-EE
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:TO-VI-EE
Last Name:NIEDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8501 NW MADISCHE RD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507-1221
Mailing Address - Country:US
Mailing Address - Phone:580-492-3614
Mailing Address - Fax:
Practice Address - Street 1:8501 NW MADISCHE RD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507-1221
Practice Address - Country:US
Practice Address - Phone:580-492-3614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-04
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery Care