Provider Demographics
NPI:1619469293
Name:SANDRA NIETO, MD, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SANDRA NIETO, MD, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:NIETO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-786-8833
Mailing Address - Street 1:PO BOX 2559
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-7359
Mailing Address - Country:US
Mailing Address - Phone:323-786-8833
Mailing Address - Fax:323-967-6067
Practice Address - Street 1:433 N 4TH ST STE 211
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-4309
Practice Address - Country:US
Practice Address - Phone:323-786-8833
Practice Address - Fax:323-967-6067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1003830258Medicaid