Provider Demographics
NPI:1982649398
Name:NIETO, CARLOS H (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:H
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 1:300 TOLLGATE RD
Mailing Address - Street 2:SUITE 301A
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886
Mailing Address - Country:US
Mailing Address - Phone:401-739-4844
Mailing Address - Fax:401-739-4415
Practice Address - Street 1:300 TOLLGATE RD
Practice Address - Street 2:SUITE 301A
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886
Practice Address - Country:US
Practice Address - Phone:401-739-4844
Practice Address - Fax:401-739-4415
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-19
Last Update Date:2008-11-25
Deactivation Date:2008-11-10
Deactivation Code:
Reactivation Date:2008-11-25
Provider Licenses
StateLicense IDTaxonomies
RI04725204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI2279-4OtherRI BLUE CROSS
RI2279-4OtherRI BLUE CROSS
RIC90554Medicare UPIN