Provider Demographics
NPI:1922114537
Name:TREVINO, RODOLFO NIETO (MD)
Entity Type:Individual
Prefix:DR
First Name:RODOLFO
Middle Name:NIETO
Last Name:TREVINO
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:PO BOX 290
Mailing Address - Street 2:
Mailing Address - City:INCHELIUM
Mailing Address - State:WA
Mailing Address - Zip Code:99138-0290
Mailing Address - Country:US
Mailing Address - Phone:509-722-7006
Mailing Address - Fax:509-722-7021
Practice Address - Street 1:39 SHORTCUT ROAD
Practice Address - Street 2:
Practice Address - City:INCHELIUM
Practice Address - State:WA
Practice Address - Zip Code:99138-0290
Practice Address - Country:US
Practice Address - Phone:509-722-7006
Practice Address - Fax:509-722-7635
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00048467207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2014383Medicaid