Individual
ROBERTO M NIETO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
2800 E BROAD ST, SUITE 504, MANSFIELD, TX 76063-6409
(817) 225-0410
(817) 419-8561
Mailing address
2800 E BROAD ST, SUITE 504, MANSFIELD, TX 76063-6409
(817) 225-0410
(817) 419-8561
Taxonomy
Speciality
Code
Description
License number
State
2084N0400X
Neurology Physician
Primary
J2967
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
083092901
—
TX
05
—
119215502
—
TX
01
—
130011976
RAILROAD MEDICARE
TX
01
—
89M402
BLUE CROSS BLUE SHIELD
TX
Enumeration date
01/10/2007
Last updated
03/20/2019
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