Provider Demographics
NPI:1811582463
Name:SOVYANHADI, MARTA LUKAS
Entity Type:Individual
Prefix:DR
First Name:MARTA
Middle Name:LUKAS
Last Name:SOVYANHADI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2198 CORDILLERA AVE
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-9517
Mailing Address - Country:US
Mailing Address - Phone:190-972-3061
Mailing Address - Fax:
Practice Address - Street 1:2198 CORDILLERA AVE
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-9517
Practice Address - Country:US
Practice Address - Phone:190-972-3061
Practice Address - Fax:909-723-0611
Is Sole Proprietor?:No
Enumeration Date:2021-03-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL861239133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA47-1681721OtherDIABETES, RENAL, HYPERTENSION AND OTHER LIFE STYLE CHRONIC DISEASES