Provider Demographics
NPI:1629476312
Name:IMTIAZ, YUSRA (RD)
Entity Type:Individual
Prefix:
First Name:YUSRA
Middle Name:
Last Name:IMTIAZ
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77555-5302
Mailing Address - Country:US
Mailing Address - Phone:409-772-0700
Mailing Address - Fax:409-747-7014
Practice Address - Street 1:301 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77555-0121
Practice Address - Country:US
Practice Address - Phone:409-772-0700
Practice Address - Fax:409-747-7014
Is Sole Proprietor?:No
Enumeration Date:2014-12-11
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered