Provider Demographics
NPI:1477554905
Name:NIE, ZETAN (MD, PHD)
Entity Type:Individual
Prefix:
First Name:ZETAN
Middle Name:
Last Name:NIE
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 N GARFIELD AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-1153
Mailing Address - Country:US
Mailing Address - Phone:626-288-6888
Mailing Address - Fax:626-236-5658
Practice Address - Street 1:616 N GARFIELD AVE STE 100
Practice Address - Street 2:
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-1153
Practice Address - Country:US
Practice Address - Phone:626-288-6888
Practice Address - Fax:626-236-5658
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC55996207R00000X
RI9916207R00000X
MA154266207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3181031Medicaid
MAJ18875OtherBC
MAJ18875OtherBC
MAG67313Medicare UPIN