Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204C00000X | Sports Medicine Doctor | 04725 | RI |
NPI | 1982649398 |
---|---|
Provider Name | Carlos H Nieto |
First Address | Warwick, RI 02886 |
Second Address | Warwick, RI 02886 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/06/2006 |
Last Update Date | 25/11/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2279-4 | RI BLUE CROSS (01) | RI |
C90554 | (02) | RI |