Provider Demographics
NPI:1487178851
Name:DIAZ, NATHAN (MS, RD, LDN)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:DIAZ
Suffix:
Gender:M
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 CALDWELL ST UNIT 135
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-1217
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:654 BEACON ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-2099
Practice Address - Country:US
Practice Address - Phone:617-536-1161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4284133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
86067011OtherCOMMISSION ON DIETETIC REGISTRATION
MA4284OtherREGISTERED DIETITIAN STATE LICENSE