Provider Demographics
NPI:1144277856
Name:NIETO, GRACIELA TERESA
Entity type:Individual
Prefix:MRS
First Name:GRACIELA
Middle Name:TERESA
Last Name:NIETO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MEDICAL X-RAY
Other - Middle Name:ON
Other - Last Name:WHEELS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1886
Mailing Address - Street 2:
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78551-1886
Mailing Address - Country:US
Mailing Address - Phone:956-722-9729
Mailing Address - Fax:956-722-9990
Practice Address - Street 1:1405 E LYON ST
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78040-2733
Practice Address - Country:US
Practice Address - Phone:956-722-9729
Practice Address - Fax:956-722-9990
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-28
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR29718335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX18511501Medicaid
TX459904Medicare PIN