Provider Demographics
NPI:1639753908
Name:VILLALOBOS MEDRAN, MARIO (MS, RDN, LDN)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:VILLALOBOS MEDRAN
Suffix:
Gender:M
Credentials:MS, RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 N RIDGEWAY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60651-3838
Mailing Address - Country:US
Mailing Address - Phone:913-263-4824
Mailing Address - Fax:
Practice Address - Street 1:1943 S MAY ST # 1F
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-3359
Practice Address - Country:US
Practice Address - Phone:312-549-8866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164008364133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered