Provider Demographics
NPI:1124576731
Name:MADRIL, PETER (RDN)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:MADRIL
Suffix:
Gender:M
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 INTERNATIONAL BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94606-3730
Mailing Address - Country:US
Mailing Address - Phone:510-535-1508
Mailing Address - Fax:
Practice Address - Street 1:1030 INTERNATIONAL BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94606-3730
Practice Address - Country:US
Practice Address - Phone:510-535-1508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-13
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered