Provider Demographics
NPI:1710018189
Name:VILLACORTA, MANUEL FERNANDO (MS, RD)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:FERNANDO
Last Name:VILLACORTA
Suffix:
Gender:M
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 MARKET ST
Mailing Address - Street 2:SUITE 324
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94102-2401
Mailing Address - Country:US
Mailing Address - Phone:415-398-2102
Mailing Address - Fax:
Practice Address - Street 1:760 MARKET ST
Practice Address - Street 2:SUITE 324
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94102-2401
Practice Address - Country:US
Practice Address - Phone:415-398-2102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA949731133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ29099ZMedicare ID - Type Unspecified