Healthcare Provider Details

I. General information

NPI: 1497409643
Provider Name (Legal Business Name): GENARO ANTONIO MARCIAL NIEVES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2022
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8890 W OAKLAND PARK BLVD STE 100
SUNRISE FL
33351-7223
US

IV. Provider business mailing address

PO BOX 250579
AGUADILLA PR
00604-0579
US

V. Phone/Fax

Practice location:
  • Phone: 954-741-3304
  • Fax: 754-222-6417
Mailing address:
  • Phone: 787-223-7924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number24082
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: