Provider Demographics
NPI:1801089503
Name:NIEVES, LUIS (MD)
Entity type:Individual
Prefix:DR
First Name:LUIS
Middle Name:
Last Name:NIEVES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4730 N HABANA AVE
Mailing Address - Street 2:STE 204
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-7163
Mailing Address - Country:US
Mailing Address - Phone:813-549-2134
Mailing Address - Fax:813-864-4436
Practice Address - Street 1:1717 PRECINCT LINE RD STE 204
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76054-3169
Practice Address - Country:US
Practice Address - Phone:855-549-7246
Practice Address - Fax:817-514-1901
Is Sole Proprietor?:No
Enumeration Date:2007-08-26
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM7476207QS0010X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX196884602Medicaid
TX196884602Medicaid