Provider Demographics
NPI:1740206440
Name:NIEVES, WALTER LEO (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:LEO
Last Name:NIEVES
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 1:11 N AIRMONT RD
Mailing Address - Street 2:STE 10
Mailing Address - City:SUFFERN
Mailing Address - State:NY
Mailing Address - Zip Code:10901-5103
Mailing Address - Country:US
Mailing Address - Phone:845-357-5525
Mailing Address - Fax:845-357-1613
Practice Address - Street 1:11 N AIRMONT RD
Practice Address - Street 2:STE 10
Practice Address - City:SUFFERN
Practice Address - State:NY
Practice Address - Zip Code:10901-5103
Practice Address - Country:US
Practice Address - Phone:845-357-5525
Practice Address - Fax:845-357-1613
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1329732084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00483358Medicaid
NYCPN-N 227967OtherWCB RATING, AUTH. #
NY31A111Medicare ID - Type UnspecifiedMEDICARE #
NYCPN-N 227967OtherWCB RATING, AUTH. #