Healthcare Provider Details

I. General information

NPI: 1922114537
Provider Name (Legal Business Name): RODOLFO NIETO TREVINO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 03/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 SHORTCUT ROAD
INCHELIUM WA
99138-0290
US

IV. Provider business mailing address

PO BOX 290
INCHELIUM WA
99138-0290
US

V. Phone/Fax

Practice location:
  • Phone: 509-722-7006
  • Fax: 509-722-7635
Mailing address:
  • Phone: 509-722-7006
  • Fax: 509-722-7021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00048467
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: