Provider Demographics
NPI:1609151489
Name:MAYCOCK, DONOVAN (NUTRITIONIST)
Entity Type:Individual
Prefix:
First Name:DONOVAN
Middle Name:
Last Name:MAYCOCK
Suffix:
Gender:M
Credentials:NUTRITIONIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16610 SAN PEDRO AVENUE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232
Mailing Address - Country:US
Mailing Address - Phone:210-778-4781
Mailing Address - Fax:210-545-0444
Practice Address - Street 1:16610 SAN PEDRO AVENUE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232
Practice Address - Country:US
Practice Address - Phone:210-778-4781
Practice Address - Fax:210-545-0444
Is Sole Proprietor?:No
Enumeration Date:2011-10-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
12138706OtherCAQH
67752OtherAMERICAN FITNESS PROFESSIONALS ASSOCIATION- CERTIFIED NUTRITION AND WELLNESS