Provider Demographics
NPI:1710085139
Name:PANTAZIS, ANN (MSRD LDN CDE)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:
Last Name:PANTAZIS
Suffix:
Gender:F
Credentials:MSRD LDN CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 NEPONSET ST FL STREET12
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-2714
Mailing Address - Country:US
Mailing Address - Phone:508-852-6175
Mailing Address - Fax:508-595-2123
Practice Address - Street 1:5 NEPONSET ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01606-2714
Practice Address - Country:US
Practice Address - Phone:508-852-6175
Practice Address - Fax:508-595-2123
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA150133N00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
61229OtherFALLON COMMUNITY HEALTH P
7807609OtherAETNA US HEALTHCARE
042472266OtherPRIVATE HEALTHCARE SYSTEM
042472266OtherTHREE RIVERS
LD0141OtherBLUE CROSS
AA16845OtherHARVARD PILGRIM HEALTHCAR
AA16845OtherHARVARD PILGRIM HEALTHCAR
MAMT0707Medicare ID - Type Unspecified