Provider Demographics
NPI:1992785653
Name:NIETO, CHARLES M (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:M
Last Name:NIETO
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 1:2960 TONGASS AVE
Mailing Address - Street 2:
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-5742
Mailing Address - Country:US
Mailing Address - Phone:907-228-4900
Mailing Address - Fax:907-228-4905
Practice Address - Street 1:4789 STATE RD
Practice Address - Street 2:
Practice Address - City:RIDGEVILLE
Practice Address - State:SC
Practice Address - Zip Code:29472-6921
Practice Address - Country:US
Practice Address - Phone:843-688-5311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR44149207R00000X
NY218850207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO44929064Medicaid
CO804081Medicare ID - Type UnspecifiedPROVIDER NUMBER
COI22628Medicare UPIN