Provider Demographics
NPI:1154377000
Name:TATEVIAN, NINA (MD PHD)
Entity type:Individual
Prefix:
First Name:NINA
Middle Name:
Last Name:TATEVIAN
Suffix:
Gender:F
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 741169
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77274-1169
Mailing Address - Country:US
Mailing Address - Phone:832-824-1866
Mailing Address - Fax:832-825-1032
Practice Address - Street 1:101 DUDLEY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-2401
Practice Address - Country:US
Practice Address - Phone:401-453-7655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD10517207ZP0101X, 207ZP0213X
TXL3158207ZP0213X, 207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
No207ZP0213XAllopathic & Osteopathic PhysiciansPathologyPediatric Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX147785301Medicaid
TX147785302OtherCIDC
TX8038J2Medicare PIN