Basic Information
| Provider Information | |||||||||
| NPI: | 1225190002 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NIETO | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4800 BELFORT RD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322566004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043987205 | ||||||||
| FaxNumber: | 9042654807 | ||||||||
| Practice Location | |||||||||
| Address1: | 4800 BELFORT RD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322566004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043987205 | ||||||||
| FaxNumber: | 9043964047 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2006 | ||||||||
| LastUpdateDate: | 05/24/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 20A8097 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | OS10072 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 16365 | 01 | FL | BCBS FL | OTHER | 279200100 | 05 | FL | MEDICAID |