Provider Demographics
NPI:1558372979
Name:NIETO, JUAN (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:
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 1:1147 LOST CREEK BLVD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78746-6338
Mailing Address - Country:US
Mailing Address - Phone:512-327-8000
Mailing Address - Fax:512-327-8801
Practice Address - Street 1:1147 LOST CREEK BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78746-6338
Practice Address - Country:US
Practice Address - Phone:512-327-8000
Practice Address - Fax:512-327-8801
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG6356207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138793806OtherCSHCN
TX138793807Medicaid
TX8L11193Medicare PIN
TX138793806OtherCSHCN
TX930074530Medicare PIN