Provider Demographics
NPI:1093394926
Name:PALOMINO TOVAR, MARTHA I
Entity Type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:I
Last Name:PALOMINO TOVAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1570 VINCENT ST
Mailing Address - Street 2:
Mailing Address - City:FALCON HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55108-1323
Mailing Address - Country:US
Mailing Address - Phone:503-410-6959
Mailing Address - Fax:
Practice Address - Street 1:1570 VINCENT ST
Practice Address - Street 2:
Practice Address - City:FALCON HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55108-1323
Practice Address - Country:US
Practice Address - Phone:503-410-6959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-07
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3552133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered