Provider Demographics
NPI:1558540286
Name:HUMPHREY, ANTHONY W (RD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:W
Last Name:HUMPHREY
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 1:220 CAMINO CORTO SPC 92
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-4949
Mailing Address - Country:US
Mailing Address - Phone:760-519-6383
Mailing Address - Fax:
Practice Address - Street 1:6655 ALVARADO RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5208
Practice Address - Country:US
Practice Address - Phone:619-229-4611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-30
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA943346133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered