Basic Information
Provider Information | |||||||||
NPI: | 1679505333 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NIEVES | ||||||||
FirstName: | MIGUEL | ||||||||
MiddleName: | ANGEL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3400 DATA DR | ||||||||
Address2: |   | ||||||||
City: | RANCHO CORDOVA | ||||||||
State: | CA | ||||||||
PostalCode: | 956707956 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9163792871 | ||||||||
FaxNumber: | 9168534730 | ||||||||
Practice Location | |||||||||
Address1: | 6305 COYLE AVE | ||||||||
Address2: |   | ||||||||
City: | CARMICHAEL | ||||||||
State: | CA | ||||||||
PostalCode: | 956080438 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9169616920 | ||||||||
FaxNumber: | 9169665063 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/06/2006 | ||||||||
LastUpdateDate: | 02/10/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/10/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | G56040 | CA | N |   | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085N0700X | G56040 | CA | N |   | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | G56040 | CA | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 00G560400 | 01 | CA | MEDI-CAL | OTHER | 300025732 | 01 |   | RAILROAD MEDICARE | OTHER |