Provider Demographics
NPI:1598336687
Name:LANDRY, MATTHEW J (PHD, RDN)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:J
Last Name:LANDRY
Suffix:
Gender:M
Credentials:PHD, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 MAPLE ST APT 4303
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063-1974
Mailing Address - Country:US
Mailing Address - Phone:985-519-4029
Mailing Address - Fax:
Practice Address - Street 1:101 MAPLE ST APT 4303
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063-1974
Practice Address - Country:US
Practice Address - Phone:985-519-4029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3205133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered