Provider Demographics
NPI:1396066171
Name:URIETO, JEFFREY (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:URIETO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1776 NORTH US 287
Mailing Address - Street 2:SUITE 220
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063
Mailing Address - Country:US
Mailing Address - Phone:817-912-8980
Mailing Address - Fax:817-912-8995
Practice Address - Street 1:1776 NORTH US 287
Practice Address - Street 2:SUITE 220
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063
Practice Address - Country:US
Practice Address - Phone:817-912-8980
Practice Address - Fax:817-912-8995
Is Sole Proprietor?:No
Enumeration Date:2010-06-16
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC32815207Q00000X
FLME128947207Q00000X
NC2013-01354207QA0505X
TXR3449207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018440800Medicaid
FLIR933YMedicare PIN
FL018440800Medicaid