Provider Demographics
NPI:1700077997
Name:MATEUS NINO, JULIO FERNANDO (MD)
Entity Type:Individual
Prefix:
First Name:JULIO
Middle Name:FERNANDO
Last Name:MATEUS NINO
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 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:905 KENILWORTH AVE
Practice Address - Street 2:UNIT A
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-1015
Practice Address - Country:US
Practice Address - Phone:704-355-3149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2018-00109207VM0101X, 207V00000X, 207VM0101X
SC36485207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
4673312355OtherMYUTMB 4673312355
TX8K5966Medicare PIN