Provider Demographics
NPI:1114670338
Name:CIVITILLO, WILLIAM N (MS RD RDN)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:N
Last Name:CIVITILLO
Suffix:
Gender:M
Credentials:MS RD RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 146TH ST
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357-3019
Mailing Address - Country:US
Mailing Address - Phone:718-309-8718
Mailing Address - Fax:
Practice Address - Street 1:1502 146TH ST
Practice Address - Street 2:
Practice Address - City:WHITESTONE
Practice Address - State:NY
Practice Address - Zip Code:11357-3019
Practice Address - Country:US
Practice Address - Phone:718-309-8718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86109420133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered