Provider Demographics
NPI:1710909809
Name:MUTIA, OFELIA BAYUTAS (RD)
Entity Type:Individual
Prefix:MS
First Name:OFELIA
Middle Name:BAYUTAS
Last Name:MUTIA
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MRS
Other - First Name:OFELIA
Other - Middle Name:MUTIA
Other - Last Name:MILLIGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:965 DULUTH HWY STE 101
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-7316
Mailing Address - Country:US
Mailing Address - Phone:678-683-2786
Mailing Address - Fax:678-683-2786
Practice Address - Street 1:965 DULUTH HWY STE 101
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-7316
Practice Address - Country:US
Practice Address - Phone:678-683-2786
Practice Address - Fax:678-683-2786
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD002082133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GALD002082Medicare UPIN