Provider Demographics
NPI:1750430419
Name:NIETO, ROBERTO M (MD)
Entity type:Individual
Prefix:
First Name:ROBERTO
Middle Name:M
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 1:2800 E BROAD ST
Mailing Address - Street 2:SUITE 504
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-6409
Mailing Address - Country:US
Mailing Address - Phone:817-225-0410
Mailing Address - Fax:817-419-8561
Practice Address - Street 1:2800 E BROAD ST
Practice Address - Street 2:SUITE 504
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-6409
Practice Address - Country:US
Practice Address - Phone:817-225-0410
Practice Address - Fax:817-419-8561
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ29672084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX130011976OtherRAILROAD MEDICARE
TX119215502Medicaid
TX89M402OtherBLUE CROSS BLUE SHIELD
TX083092901Medicaid
TX00J07HMedicare ID - Type UnspecifiedGROUP MEDICARE
TX119215502Medicaid
TX083092901Medicaid