Provider Demographics
NPI:1508473695
Name:CUCKLER, JOSIAH MICHAEL (RD)
Entity Type:Individual
Prefix:MR
First Name:JOSIAH
Middle Name:MICHAEL
Last Name:CUCKLER
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 HIDDEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-1601
Mailing Address - Country:US
Mailing Address - Phone:970-581-1206
Mailing Address - Fax:
Practice Address - Street 1:45 HIDDEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-1601
Practice Address - Country:US
Practice Address - Phone:970-581-1206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
CA86145628133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty