Provider Demographics
NPI:1467765032
Name:CHAVEZ, MYRIAN JEANETTE (MS, RD, LD, CDE)
Entity Type:Individual
Prefix:MS
First Name:MYRIAN
Middle Name:JEANETTE
Last Name:CHAVEZ
Suffix:
Gender:F
Credentials:MS, RD, LD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7834 BROADWAY ST
Mailing Address - Street 2:#601
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-2568
Mailing Address - Country:US
Mailing Address - Phone:210-372-2997
Mailing Address - Fax:
Practice Address - Street 1:1200 BROOKLYN AVENUE
Practice Address - Street 2:SUITE 240
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-4830
Practice Address - Country:US
Practice Address - Phone:210-225-4511
Practice Address - Fax:210-225-4514
Is Sole Proprietor?:No
Enumeration Date:2010-07-23
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT07511133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX961737OtherREGISTERED DIETITIAN
TX2011-0463OtherCERTIFIED DIABETES EDUCATOR