Basic Information
| Provider Information | |||||||||
| NPI: | 1861848947 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NIETO | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8950A (CAMPUS DELIVERY CODE) 2450 RIVERSIDE AVE | ||||||||
| Address2: | PEDIATRICS EDUCATION OFFICE 1ST FLOOR EAST BUILDING | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126244477 | ||||||||
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| Practice Location | |||||||||
| Address1: | 280 S MAIN ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928683852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146344567 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2016 | ||||||||
| LastUpdateDate: | 07/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2080S0010X | A168679 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Sports Medicine |
No ID Information.