Provider Demographics
NPI:1336105881
Name:SHOMOS, AUDREY T (CD)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:T
Last Name:SHOMOS
Suffix:
Gender:F
Credentials:CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 N WASHINGTON ST
Mailing Address - Street 2:DEAN MEDICAL CENTER
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-2908
Mailing Address - Country:US
Mailing Address - Phone:608-755-3500
Mailing Address - Fax:608-755-3792
Practice Address - Street 1:580 N WASHINGTON ST
Practice Address - Street 2:DEAN MEDICAL CENTER
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-2908
Practice Address - Country:US
Practice Address - Phone:608-755-3500
Practice Address - Fax:608-755-3792
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1439-029133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI6391OtherDEAN HEALTH INSURANCE
WI100374150Medicare PIN
WIP00137357Medicare PIN
P52272Medicare UPIN
WI028354340Medicare PIN