Provider Demographics
NPI:1659814077
Name:DOUBLET, MARK ANTHONY (RD, CDE)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ANTHONY
Last Name:DOUBLET
Suffix:
Gender:M
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 WESTVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-6404
Mailing Address - Country:US
Mailing Address - Phone:516-523-4413
Mailing Address - Fax:
Practice Address - Street 1:75 N COUNTRY RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2119
Practice Address - Country:US
Practice Address - Phone:631-686-2505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-03
Last Update Date:2016-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1005065133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered