Provider Demographics
NPI:1811950132
Name:NIETO, JOSE G (MD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:G
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 1:16501 NW 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33169-6005
Mailing Address - Country:US
Mailing Address - Phone:305-354-4558
Mailing Address - Fax:
Practice Address - Street 1:16501 NW 2ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33169-6005
Practice Address - Country:US
Practice Address - Phone:305-354-4558
Practice Address - Fax:305-354-3884
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME57329174400000X
FLMR57329207RN0300X
FL57329207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE59530Medicare UPIN
10927Medicare ID - Type Unspecified