Basic Information
| Provider Information | |||||||||
| NPI: | 1568425080 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NIEVES CRUZ | ||||||||
| FirstName: | BEDFORD | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | NIEVES | ||||||||
| OtherFirstName: | BEDFORD | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8166 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HOUMA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703603404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9852266428 | ||||||||
| FaxNumber: | 9858587335 | ||||||||
| Practice Location | |||||||||
| Address1: | 8166 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HOUMA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703603404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858734141 | ||||||||
| FaxNumber: | 9858514307 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2006 | ||||||||
| LastUpdateDate: | 06/27/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD11360R | LA | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080N0001X | MD.11360R | LA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 370007352 | 01 | RAILROAD MEDICARE | OTHER | 02286071 | 05 | MS | MEDICAID | 1664324 | 05 | LA | MEDICAID |