Provider Demographics
NPI:1144500208
Name:VIZTHUM, DIANE A (RD)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:A
Last Name:VIZTHUM
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 1:2360 W JOPPA ROAD
Mailing Address - Street 2:STE 210
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093
Mailing Address - Country:US
Mailing Address - Phone:410-614-3372
Mailing Address - Fax:
Practice Address - Street 1:600 N WOLFE ST
Practice Address - Street 2:NUTRITION CLINIC, HALSTED 153
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-1900
Practice Address - Country:US
Practice Address - Phone:410-955-6716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-22
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX3229133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered