Provider Demographics
NPI:1083694202
Name:BIRD, EVELYN (RD)
Entity Type:Individual
Prefix:MS
First Name:EVELYN
Middle Name:
Last Name:BIRD
Suffix:
Gender:F
Credentials:RD
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 115
Mailing Address - Street 2:
Mailing Address - City:SACATON
Mailing Address - State:AZ
Mailing Address - Zip Code:85247-0115
Mailing Address - Country:US
Mailing Address - Phone:602-528-1340
Mailing Address - Fax:602-528-1296
Practice Address - Street 1:483 W. SEED FARM RD.
Practice Address - Street 2:
Practice Address - City:SACATON
Practice Address - State:AZ
Practice Address - Zip Code:85247
Practice Address - Country:US
Practice Address - Phone:602-528-1340
Practice Address - Fax:602-528-1296
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ723654133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ8EB257, 58, 59Medicare ID - Type Unspecified