Provider Demographics
NPI:1003448085
Name:SERBACK, MARIANA OLGA (MS, RDN)
Entity Type:Individual
Prefix:MRS
First Name:MARIANA
Middle Name:OLGA
Last Name:SERBACK
Suffix:
Gender:F
Credentials:MS, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19500 WOODSIDE DR
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-4458
Mailing Address - Country:US
Mailing Address - Phone:315-778-9218
Mailing Address - Fax:
Practice Address - Street 1:19500 WOODSIDE DR
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4458
Practice Address - Country:US
Practice Address - Phone:315-778-9218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86050685133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered