Healthcare Provider Details

I. General information

NPI: 1659772515
Provider Name (Legal Business Name): JOSE NIEVES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2014
Last Update Date: 10/12/2020
Certification Date: 10/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14540 OLD SAINT AUGUSTINE RD STE 2391
JACKSONVILLE FL
32258-7418
US

IV. Provider business mailing address

14540 OLD SAINT AUGUSTINE RD STE 2391
JACKSONVILLE FL
32258-7418
US

V. Phone/Fax

Practice location:
  • Phone: 904-647-6946
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number34043-R
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME146349
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: