Provider Demographics
NPI:1508161449
Name:BERMUDEZ, ELSA VICTORIA (RD)
Entity Type:Individual
Prefix:MS
First Name:ELSA
Middle Name:VICTORIA
Last Name:BERMUDEZ
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MS
Other - First Name:ELSA
Other - Middle Name:VICTORIA
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RD
Mailing Address - Street 1:4159 NEWPORT CT
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-1436
Mailing Address - Country:US
Mailing Address - Phone:909-425-6273
Mailing Address - Fax:909-425-7069
Practice Address - Street 1:3102 E HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:PATTON
Practice Address - State:CA
Practice Address - Zip Code:92369-7813
Practice Address - Country:US
Practice Address - Phone:909-425-6273
Practice Address - Fax:909-425-7069
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1037396133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered