Healthcare Provider Details

I. General information

NPI: 1184062135
Provider Name (Legal Business Name): RAYMOND MICHAEL NIETO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2013
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MEDICAL DR
LAKE JACKSON TX
77566-5674
US

IV. Provider business mailing address

100 MEDICAL DR
LAKE JACKSON TX
77566-5674
US

V. Phone/Fax

Practice location:
  • Phone: 979-297-4411
  • Fax: 979-299-2878
Mailing address:
  • Phone: 979-297-4411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberS5452
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberS5452
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: